Camper health form
Camp
Camper’s name
Date of birth
Session or week
Contacts
Parent or guardian
Phone
Second parent or guardian
Phone
Emergency contact who is not a parent
Phone
Doctor and insurance
Doctor’s name
Doctor’s phone
Insurance company
Policy number
Allergies
Food allergies
Medicine allergies
Other allergies, such as bees or latex
The reaction, and what to do
Carries an epinephrine auto-injector:YesNo
Health
Conditions we should know about, such as asthma, diabetes or seizures
Medicines taken at home
Medicines to give at camp (fill in a medication log too)
Date of last tetanus shot
Food needs
Activities to limit, and why
Swimming:Does not swimBeginnerStrong swimmer
This information is correct. I give permission for camp staff to give first aid and to get emergency care for my child.
Parent or guardian signature
Date
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