Camp Bethel 2018 Winter Camper Health form
A parent or legal guardian must complete and submit this form. Information on this form will be held confidential by the directors, health coordinator and camp counselors. The intent of this form is to provide information needed to provide appropriate emergency care. In any emergency, parent/guardian will be immediately contacted. If needed, submit additional information or descriptions via e-mail to CampBethelOffice@gmail.com. You will have the opportunity to provide changes or updates to this information with the health coordinator at check-in on the first day of camp. If you have medical insurance, e-mail or bring a scan/image of the front & back of your medical insurance card; (not required for camp attendance).
SCROLL THIS FORM DOWN AS YOU GO, and be sure to click the SUBMIT button at the bottom of the form! Items with a red * asterisk are REQUIRED items.
Camper's LAST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Your answer
Camper's FIRST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Your answer
Camper's Middle Initial
Your answer
Gender - male or female *
Dates of Camp Attendance *
Choose the dates that most closely match your program.
Camper birth date *
month / day / year; example: 03/09/1999
Your answer
First & Last Name of custodial Parent's/Guardian who is the primary contact for this camper. *
This is the parent/guardian(s) with whom the camper has primary residence and who is our primary contact.
Your answer
City and State of residence. *
Thank you for using correct capitalization and correct state abbreviation.
Your answer
Cell phone of custodial Parent/Guardian
include area code, (ex: 540-555-1234)
Your answer
Home phone of custodial Parent/Guardian
include area code, (ex: 540-555-1234)
Your answer
Work phone of custodial Parent/Guardian
include area code, (ex: 540-555-1234)
Your answer
Emergency Contact Information
In case of emergency or if we need to give important information to parents, but we cannot reach parents, who should we contact?
Who to call if parent/guardian is not available
Your answer
Relation to camper
Your answer
Their cell phone
include area code, (ex: 540-555-1234)
Your answer
Their home phone
include area code, (ex: 540-555-1234)
Your answer
ALLERGIES & RESTRICTIONS
List all known allergies and restrictions. Describe the severity of any allergies or restrictions. Describe your child's reaction and the best management of the reaction. Describe the best accommodation of any restrictions. If none, leave blank or write NONE.
Medication allergies
Your answer
Food allergies
Your answer
Other or environmental allergies
Your answer
The following Dietary restrictions apply to this camper:
Your answer
Explain any restrictions or exemptions to camp activities:
What cannot be done; what adaptations, accommodations or limitations are necessary?
Your answer
Other restrictions or health concerns?
Your answer
MEDICATION THAT WILL BE NECESSARY DURING CAMP:
List all medications (including non-prescription) for this camper that you will be transferring to our Health Coordinator at camp check-in. Keep meds in the original packaging naming prescribing physician, name of med, dosage, frequency, etc.
Will this camper need medication during camp?
List all planned medications this camper will need during camp:
Also, plan to complete a brief "Medication Instructions" form at check-in on the first camp day.
Your answer
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS:
Check the box for each medication allowed for your camper. WE RECOMMEND CHECKING ALL BOXES. Camp Bethel has a supply of over-the-counter medications to treat everyday aches and pains. In case of headaches, low grade fever, slight upset stomach, mild diarrhea, mild allergic reactions or cold symptoms, the Camp Bethel Health Coordinator has my permission to administer the following to my child:
History
MEDICAL HISTORY:
Describe any past or current injury, illness, disease, treatment, surgery, or affliction the camp should know in case of emergency.
Your answer
ADDITIONAL INFORMATION:
Describe other physical, emotional, or behavioral concerns or any conditions requiring medication, treatment, or special restrictions or considerations while at camp.
Your answer
Parent/Guardian Health Form Verification:
"I verify that the information on this Health Form is correct and complete as far as I know. This form may be copied for camp records. I will provide updates (if any) to this information at check-in the first day of camp."
I verify this information. (This is a required question.) *
After agreeing (clicking "YES"), be sure to SCROLL THIS FORM DOWN to the SUBMIT button in order to send us this camper Health information!
**To complete this form, click SUBMIT.
If you do not click "Submit" we will not receive your camper's information, so be sure to click SUBMIT. Thanks! Once submitted, you will be directed to a "Thank You" message with a link to the Confirmation Packets page of our web site. Be sure to print/save your important Confirmation Packet.
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