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Camp Blue Diamond - Health Form 2019
This Online Health Form is only for campers who Pre-Registered for Summer Camp 2019 during June or July 2018.
Those campers are registered for camp, but did not complete a Health Form. If you have not registered for Summer Camp 2019 yet, use the Camp Blue Diamond Online Registration Form.

Complete an Online Health Form for each camper you Pre-Registered last summer. If completing an Online Health Form for a Kiddie Camper, only do the child. Adults do not need to do Health Forms.

If you have any questions, please contact us at:
Camp Blue Diamond Inc
P.O. Box 240, 4013 Blue Diamond Dr., Petersburg, PA 16669
Ph.: (814) 667-2355 / Email: campbluediamond@verizon.net / Website: campbluediamond.org

Camper's Last Name *
Your answer
Camper's First Name *
Your answer
Camper's Middle Initial
Grade *
Current grade level - the one he/she is completing in the Spring of 2019
Street Address of P.O. *
Your answer
City *
Your answer
State *
Use postal abbreviation (examples: for Pennsylvania use PA, for New York use NY)
Your answer
Zip *
Your answer
Birth Month *
Birth Day *
Birth Year *
Parent/Guardian's Name *
Your answer
Relationship to Camper *
Your answer
Preferred Phone Number *
Your answer
Secondary Phone Number
Your answer
Emergency Contact Name *
Please give the name of an adult who can serve as an emergency contact, in the event camp needs to contact the parent/guardian, and she/he is unavailable. Emergency Contact may be another parent if parents not living together.
Your answer
Relationship to Camper
Your answer
Emergency Contact's Preferred Phone Number *
Your answer
Emergency Contact Secondary Phone Number
Your answer
Are there circumstances regarding custodial relationships camp needs to be aware of before releasing a child to a parent?
If 'Yes' to previous question, please explain:
Your answer
Is the Camper covered by Medical Insurance? *
Insurance Carrier Name
Your answer
Insurance Policy #
Your answer
Name of Primary Insured Person
Your answer
Insurance Carrier Phone Number
Your answer
Physician's Name
Your answer
Physician's Phone Number
Your answer
Allergies *
Required
Please list specific allergies and reactions
Your answer
Asthma *
If 'Yes' to previous question, please explain type and severity
Your answer
Medications *
Medication #1
List name of medication, prescription or over-the-counter, the camper takes routinely. When coming to camp be sure to bring enough medication to last the entire camp session. Medications must be in the original packaging/bottle. Prescription medications must identify the prescribing physician, the name of the medication, the camper's name, dosage and frequency of administration. Medications may not be expired.
Your answer
Dosage for Medication #1
Your answer
Time to Administer Medication #1
Your answer
Reason for Taking Medication #1
Your answer
Medication # 2
List name of medication, prescription or over-the-counter, the camper takes routinely.
Your answer
Dosage for Medication #2
Your answer
Times to Administer Medication #2
Your answer
Reason for Taking Medication #2
Your answer
Medication # 3
List name of medication, prescription or over-the-counter, the camper takes routinely.
Your answer
Dosage for Medication #3
Your answer
Times to Administer Medication #3
Your answer
Reason for Taking Medication #3
Your answer
Other Medications
List any other medications the camper takes on a routine basis, with information about dosage, times to administer and reason for taking.
Your answer
List any medications taken during the school-year, prescription or over-the-counter, that the camper may not take during summer camp.
Your answer
Activity Restrictions *
I have reviewed the program & activities of the camp and feel the camper can participate without restrictions
If 'No' to previous question, please list restrictions or needed adaptations
Your answer
General Health Questions: *
Does the camper have any of the following Health Concerns?
Yes
No
Joint problems (knees, ankles)
Sleepwalks
Wears glasses, contacts
Has frequent headaches
Wets the bed
Received mental health treatment
If you answered 'Yes' to any of the Health Concerns, please explain:
Your answer
Dietary Needs or Restrictions *
Required
If you checked 'Other' for Dietary Needs or Restrictions, please explain:
Your answer
Past Medical Treatment
Please list any other past medical treatment that is beneficial for camper care.
Your answer
Current Concerns
Provide other information on current or past physical, mental or psychological conditions requiring medication, treatment, or special restrictions/consideration while at camp, including significant life events that continue to affect the camper's life: (abuse, death of a loved one, family change, adoption, foster care, new sibling, survived disaster, etc.).
Your answer
Date of Last Tetanus Shot - Month *
Date of Last Tetanus Shot - Year *
I, Parent/Legal Guardian, attest that all immunizations of the camper are up to date as required for school attendance *
Over-The-Counter Medications *
I give permission for my child to be given over-the-counter medications including: ibuprofen, diphenhydramine (Benadryl), acetaminophen, throat spray, sting-kill swabs, first aid spray, antibiotic ointment, calamine lotion, eye irrigating solution and cough drops.
If 'No' to Over-the-Counter Medications, Please List the Medications your child cannot receive:
Your answer
Parental Authorization *
By printing your full name below, you are affirming that all information provided, including health information, is correct and complete as far as you, the parent/legal guardian, know. The camper has permission to take part in all camp activities except those noted. You, as the parent/legal guardian give permission to Camp Blue Diamond leaders to provide routine health care, administer prescribed medications, and seek emergency treatment including x-rays or routine tests. You, as the parent/legal guardian, agree to the release of any records necessary for insurance purposes, and give permission to camp to arrange necessary health related transportation for your child. In the event you cannot be reached in an emergency, you give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the camper. Your child's Health Information may be photocopied for trips out of camp.
Your answer
Camper/Parent Agreement *
By printing your full name below, you, as the camper's parent/legal guardian, are affirming that you and the camper agree to abide by all regulations concerning personal conduct and use of camp property. You are affirming that should it become necessary for the camper to return home, the parents/guardians will abide by camp's decision and provide transportation. The parent/legal guardian are giving permission to photograph or video the camper. Use of photos and videos will be limited to camp publications, including: the website, summer video, group photos and promotional information including Facebook. You may request that your child's image not be used in publications by adding a note after your printed signature.
Your answer
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