ISC Summer Camp Health & Wellness Forms (one per child)
HEALTH & WELLNESS FORMS
Camper Name *
Your answer
Home Address *
Your answer
Home Phone Number *
Your answer
Cell Phone Number *
Your answer
Child's DOB *
Your answer
Boy/Girl *
Your answer
Current Grade: *
Returning Camper *
Required
Referred By: (must be listed at time of enrollment)
Your answer
How did you hear about our camp?
Your answer
Parent/Guardian Name *
Your answer
Home Phone:
Your answer
Home Address: *
Your answer
Work Number:
Your answer
Email Address (this email will receive all camp information and notices) *
Your answer
Cell Phone Number: *
Your answer
Parent/Guardian #2 Name:
Your answer
Parent/Guardian #2 Home Phone:
Your answer
Parent/Guardian #2 Home Address:
Your answer
Parent/Guardian #2 Work Phone:
Your answer
Parent/Guardian #2 Email Address:
Your answer
Parent/Guardian #2 Cell Phone Number:
Your answer
What does your child like to do in his/her free time?
Your answer
Describe how your child interacts with his/her peers?
Your answer
Have there been any major changes in your family situation in the past year (move, separation, divorce, death, new school etc.) If so what effect if any did this have on your child?
Your answer
Is your child receiving any special help with emotional or behavior concerns at home or at school? (psychiatrist, counselor, social worker etc.) If so, please explain:
Your answer
Is there anything else you would like us to know about your child that will aide us in helping him/her have a safe and enjoyable summer? Any specific concerns about your child?
Your answer
Any photos/video footage taken while your child is at camp may be used for promotional purposes in print media and/or internet promotion. No financial compensation is available should such a picture/video be used. If you DO NOT wish to have your child appear in photos/videos used to promote our camp please check NO PHOTOS
Insurance Company:
Your answer
Policy #
Your answer
Doctor's Name & Phone Number
Your answer
Primary Insured:
Your answer
In the event of an emergency, please have an ambulance take my child to:
Your answer
Has your child been identified as needing support or supplemental services during the school year in any of the following areas:
Please describe the nature of these services:
Your answer
Does your child have an epi pen? *
Does your child have an inhaler? *
Is your child allergic to any medications, animals, or insect stings? If so please explain:
Your answer
Does your child have a FOOD ALLERGY? *
What food allergy does your child have?
Your answer
Does your child take any daily medications? If yes, please list medication and dosage.
Your answer
Does your child have any medical/physical restrictions? Please explain:
Your answer
Does your child suffer from the following:
If Other please explain here:
Your answer
Do you give us permission to administer tylenol to your child? *
If yes, please list your child's weight and correct dosage for Children's Tylenol
Your answer
We are required by the NJ Department of Health and Senior Services to have a current copy of each camper's Immunization Records on file. IF your child attended camp last year and HAS NOT had any immunizations since last summer you may check use last years immunization records below and we will pull the form. (we can only reuse immunization records once). *
I certify that the health history information provided on this form is correct. My child has permission to engage in all camp activities and be transported to and from field trips that I have selected for him/her. In the event that I cannot be reached in an emergency, I give permission to the physician selected by the camp to hospitalize and secure proper treatment for my child as named above. I will notify the Camp Director if there are any changes to my child's medical information in writing. Please submit signature electronically: *
Your answer
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