Medical History
To be filled out by a parent or guardian
Campers name: *
Your answer
Birth date: *
MM
/
DD
/
YYYY
Age: *
Your answer
Gender: *
Your answer
Parent(s) or Guardian(s) name: *
Your answer
Parent(s) or Guardian(s) best reach phone number: *
Your answer
Parent(s) or Guardian(s) best reach email: *
Your answer
Parent(s) or Guardian(s) home address: *
Your answer
Please list the name, phone number and relationship to the camper of the first person to contact if you are not available in an emergency *
Your answer
Please list the name, phone number and relationship to the camper of the first person to contact if you are not available in an emergency *
Your answer
Health History: Check yes or no below *
Yes
No
Ever been hospitalized?
Ever had surgery?
Have recurrent/chronic illness?
Had a recent infectious disease?
Had a recent injury?
Had asthma/wheezing
Have diabetes
Had seizures
Had chronic headaches?
Wear glasses or contacts?
Had fainting or dizziness?
Passed out or had chest pain during exercise?
Have problems with periods/menstruation
Sleepwalk?
Had back or joint problems?
Have a history of bedwetting?
Have problems with diarrhea or constipation?
Have any skin problems?
Been diagnosed with ADHD?
Ever been treated for an eating disorder?
Have any significant mental health history we should know about?
Health History: Please let us what we need to know about boxes checked yes above.
Your answer
Allergies: Please list all allergies including food, insect stings, medication and environmental. *
Your answer
Please list any activities that the camper should not be participating in
Your answer
Please list the name, dose and time of day taken for all prescription medication your camper takes.
Your answer
Please list anything else we may need to know about your camper's health
Your answer
Important: Please notify camp if this camper is exposed to any communicable disease during the three weeks prior to camp attendance. *
Required
Medical Emergency Care Authoriation (required by the State of Michigan for the care of your child): I hereby consent to routine, non-surgical medical care for the above minor child while in residence at Camp Cedar Lodge. In the event that I cannot be reached in an emergency, I hereby give permission to the phsician selected by the camp director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as name above. Sign and date: *
Your answer
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