Camper Health HistoryPlease provide the following information for your camper…Please note, if filling out for siblings, submit separate forms. Camper Name * First Name Last Name Allergies * Please list specific allergies below. No Known Allergies Allergic to Food Allergic to Medicine Allergic to Environment Other Please list all known allergies. Diet & Nutrition * Please check all that apply. List specific below. Eats a Regular Diet Vegetarian Vegan Gluten Intolerant Lactose Intolerant Other Please list any details we should know about your camper's diet. Restrictions * No Restrictions, I have reviewed the program and activities and feel my camper can participate without restrictions. Yes Restrictions, I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations (below). Please list restrictions. Parent/Guardian Authorization for Health Care * This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status. Yes, I grant consent. No, I do not grant consent. Parent/Guardian Name * First Name Last Name Relationship to Camper * Date * MM DD YYYY Thank you!
