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Health Statement 2008 |
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To Be Completed and Signed by Parent Name______________________________________ Birth date __________ Sex: F M Camp Program: _____ Juniors (grades 3-5) _____
Intermediates (grades 6-8) Height:________ Weight:______ Does your child wear glasses?_____ Should the nurse/staff be aware of any physical or emotional problems that your child has experienced but is now under control and won't be a problem at camp?
Has your child had any surgery/injury which may affect participation in camp? Please explain. Remember, your child is expected to participate in all the camp program activities.
Does your child have any of the following? Drug Allergies_____________________ Describe reaction_________ Other allergies ____________________ Describe reaction_________ Diabetes ________ Medication ______________________________ Heart Condition ____ Medication ____________________________ Epilepsy/Convulsions_____ Medication ________________________ Emotional Problems _____ Medication _________________________ Ear Problems _____ Medication ______________________________ *Asthma ___________ Medication ____________________________ *Bed Wetting _____________________________________________ *Please describe: Is your child currently taking any medication other than those already listed? If so, please list medications and reason: ____________________ ____________________________________________________________ My child’s immunizations are up to date. Yes____ No_____ Date of last tetanus shot: ________ Physician's signature ________________________________________ This camper is physically fit to participate in all camp activities. Information in the event of an emergency: Doctor’s name:______________________ Phone (___)________________ Address________________________ City_____________ State_______ Name of Primary Insurance Co. ___________________________________ Group number or Policy number ___________________________________ ***Please attach a photocopy of your child's health insurance card.*** *This camper does not have health insurance. _____________ List the names of two persons who can assume responsibility for your child in the event of an emergency if you cannot be reached: Name_________________________ Phone (____)___________________ Name_________________________ Phone (____)____________________
If you will be out of town during the week of camp, please provide location and number of where you can be reached. Location________________________________ Phone (____)__________ Dates you will be there:______________________________________ I (we) give permission for my child to receive
over the counter medication such as Tylenol, ibuprofen, antidiarrheal
medication, antibacterial ointment, throat lozenges, eye wash solutions
and the like by any of the registered staff members.
I UNDERSTAND THAT IN THE EVENT OF A SERIOUS ILLNESS OR INJURY, I WILL BE NOTIFIED. IF THIS IS NOT POSSIBLE, I HEREBY GIVE PERMISSION FOR EMERGENCY TREATMENT AS RECOMMENDED BY THE APPROPRIATE MEDICAL PERSONNEL. NAME__________________________________________ SIGNATURE_____________________________________ ADDRESS_________________________________________ CITY___________________ STATE _____ZIP_________ PHONE: home (____)_________work (____)_____________ DATE________________________________________ Please return this completed form with the registration form to: Camp Luther by May 1, 2008 |
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