Camper's Name

First Name

Last Name

Camper's Birthdate

YYYY

Camper's Age

Grade completed in June 2015

Parent/Guardian #1

Parent/Guardian #1 Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Parent/Guardian #2

Parent/Guardian #2 Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Alternate Emergency Contact

Alternate Emergency Contact Name

First Name

Last Name

Relationship

Phone Number

(###)

###

####

What Kind of Phone is this?

Insurance Information

Health Insurance Company

ID/Policy No.

Group No.

Are you a member of an HMO?

Medical Information

Name of Primary Care Physician

Date of Last Physical

YYYY

Describe if the camper has any special needs:

List any medications the camper is currently taking or has been taking in the last year:

List any medication that camper is allergic to:

What kind of reaction:

Is there any non-prescription medications you DO NOT want your child to receive?

Has the camper had a tetanus shot in the past five years?

Has the camper ever had hepatitis?

Has the camper ever had a history of behavioral or emotional problems?

Describe the above history:

(if applicable)

Other conditions in addition to above:

Explanation:

Chronic or reoccurring illness:

Disablilities

Limitations or suggestions regarding activities

Any other condition requiring medication, special care, or special diet:

Is there any other information about the camper that we should know in seeking to best minister to his/her needs at camp?

i. e. first time away from home, etc.

Parent Authorization: This health history and other information requested are accurate to the best of my knowledge. The child herein described has permission to engage in all prescribed camp activities, except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp Health Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. I have read and fully understand this statement.

Parent/Guardian Name

Please enter your name. We will later ask you to sign this form upon Check-in.

First Name

Last Name

Today's Date

YYYY

Your relationship to the camper:

Thank you for completing the Medical Form for Highland Park Youth Camp. If you have not done so yet, please complete GVH Emergency Room Consent form. Once these forms have been entered, your registration is complete.

Highland Park Youth Camp - Medical Form