Health Form

* Camper/Volunteer's First Name

* Last Name

* Name of Camper/Volunteer’s Physician/Clinic

* Physician's Phone Number

* Health Plan Name

* Health Plan Policy Number

* Name of Policy Holder

* Policy Holder's Date of Birth

(Please check box AND explain below)

Yes

No

* Any restrictions (swimming, sports, etc.) (SPECIFY BELOW)

Yes

No

* Asthma or other lung problem

Yes

No

* Bleeding/clotting disorder

Yes

No

* Blood disorder (other type)

Yes

No

* Diabetes

Yes

No

* Ear Infections

Yes

No

* Gastrointestinal disorder (other than celiac)

Yes

No

* Heart defects

Yes

No

* Kidney disease

Yes

No

* Muscular or skeletal disorder

Yes

No

* Sleeping disorder or disturbance

Yes

No

* Seizures

Yes

No

* Any prior surgical operations

Yes

No

* Any restrictions (swimming, sports, etc.) (SPECIFY BELOW)

Chronic Health Conditions

ALLERGIES

Specify TYPE of Reaction

Yes

No

* Medications

Yes

No

* Nuts

Yes

No

* Insect Stings

Yes

No

Animals

Yes

No

Hayfever

Other Foods (apart from gluten)

Please explain any boxes that are checked, severity of the condition, any suggestions for treatment or information you feel is important for the condition, and any other medical or food disorders you feel would be important to know:

IMMUNIZATIONS (Year of Last Booster)

* Tetanus

Diphtheria/Pertussis

Consent for Emergency Medical Treatment

Consent For Emergency Medical Treatment

I confirm this health history is complete and accurate. I know of no reason(s), other than the information noted on this form, why my child/I should not participate in camp activities. I confirm I am the legal guardian of the minor listed above or I am the adult listed above. Entering my name into the space below authorizes the officers, group leaders, or agents of Camp Celiac/Camp Arroyo to obtain and administer first aid and/or to consent to medical, surgical, dental and related treatment as might be required for the immediate care of the camper/adult listed above in the event of an emergency and for ongoing care of chronic health conditions. I provide additional permission for the administration of non-prescription medications (such as antihistamines, acetaminophen, ibuprofen, etc.) or prescription medications, if needed, unless otherwise noted on the form under “health conditions”.

* First and Last Name

* Date (MM/DD/YYYY)

* Relationship to Person Above

MEDICATIONS

Adults and campers will need to bring all essential medicines with them to check-in. To minimize disruption to the camp schedule, we request that non-essential substances (e.g. vitamins and herbal supplements) be kept at home. We require that all essential medications be pre-sorted into a seven-day pill sorter in advance, along with a printed schedule of when the medications should be taken. All essential medications (including over-the-counter medications) will be handed to the medical staff at check-in, stored in the infirmary and distributed at the required schedule. Our medical facility is also stocked with over the counter medicines that may be needed for minor colds and aches.

List below the name(s) of any essential medications needed on a regular or occasional basis, and check the approximate time(s) when taken. For example, if a medication is taken ONLY in the morning, check ONLY the "morning" box for that medication.

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

Medication Name

Purpose

Morning

MidDay

Evening

Bed

As Needed

* Indicates Response Required


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