Personal Health and Medical History Form

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Please submit one form for each camper.

Camper First Name *

Camper Last Name *

Parent/Guardian Name *

Parent/Guardian Phone *

Camper Physician Name *

Camper Physician Phone *

Camper Health/Accident Insurance Plan Name *

Camper Health/Accident Insurance Policy Number *

Camper Has Allergies *

Food, Medications, Environment (such as Insects, Plants), Other

Yes (list all allergies and describe reaction below)

Camper Allergies (if applicable)

List all allergies and describe reaction.

Does the camper have a history of any of the following conditions?

Check all that apply.

Asthma

Attention-deficit/hyperactivity disorder

Diabetes

Seizures

Significant event or recent injury that may impact camper while at camp

Other:

List medications and doses to be taken at camp

Over-the-Counter Medications

The on-site nurse will have over-the-counter medications available in age/weight appropriate doses. Please check the boxes below indicating your consent to your camper receiving age/weight appropriate doses at the nurses discretion.

Tylenol (for headaches and pain relief)

Benadryl (for allergies or difficulty sleeping)

Tums (for indigestion and upset stomach)

Topical Antiseptic (for cuts and scrapes)

Check this box if you do not want over-the-counter medicines administered.

Other:

Date of last tetanus booster? *

YYYY

Additional Comments

Please provide in the space below any additional information about the camper’s health you deem important or that may affect the camper’s ability to fully participate.

Signature of Parent/Guardian *

I give permission for full participation at camp, subject to limitations noted herein. In case of emergency, I understand every effort will be made to contact me (or the emergency contact provided during registration). In the event I (or the emergency contact) cannot be reached, I hereby give my permission to a licensed healthcare practitioner to provide medical treatment for this camper while they are attending God's Kids Bible Camp.

Date of Parent/Guardian Signature/Submission *

YYYY

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