2023 Day Camp Health History Form - St. Johannes Lutheran Church

Dates of Camp:

We look forward for your child's experience at our Day Camp!

This Day Camp is provided by St. Johannes Lutheran Church. We want to provide your child with the best possible day at camp, including spiritual, physical, and social growth. You can help by carefully filling out this form. Each camper must have a completed health form on file or WILL NOT be admitted to Day Camp.

Basic Information

Camper Last Name

Camper First Name

Preferred Name

Age

Birth Date (dd/mm/yyyy)

Gender

Female Male Other

Address

Parent/Guardian 1 Name

Parent/Guardian 1 Phone

Parent/Guardian 1 Email

This address will receive a confirmation email

Parent/Guardian 2 Name

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone

Name of Child's Physician

Physician Phone

Health Insurance Information:

St. Johannes Lutheran Church has secondary accident insurance. The parent/legal guardian is responsible for all charges associated with an accident or illness.

Carrier Name

Carrier Address

Policy #

Policy Holder's Name

Policy Holder's SS#

Policy Holder's Date of Birth

Medical Release and Authorization for Treatment

This day camp is provided by St. Johannes Lutheran Church as a service to the community. As parent/legal guardian of the camper, the undersigned authorizes St. Johannes Lutheran Church, its delegated leaders, directors, and medical personnel they have selected to consent to any medical/hospital care deemed necessary. I consent to release this health history and examination form to the emergency room, hospital, or doctor’s office providing care. Day Camp leaders will endeavor but are not required, to communicate with me before treatment. The undersigned releases St. Johannes Lutheran Church and its designated leaders and directors from any liability and claims arising from any consent given in good faith in connection with diagnosis or treatment. The undersigned certifies that he/she has full authority to sign this Release and Authorization. This completed form may be photocopied.

Parent or Guardian Signature (typed will act as signature)

Date

Health Information

Describe any current physical, mental, or psychological health conditions requiring medication, treatment, or special restrictions or considerations while at camp:

Activities from which the camper should be exempted for health or other reasons:

Allergies: Please list any allergies (food, medicine, insect stings, etc.):

Asthma:

Asthma Triggers:

Nutritional/Dietary Restrictions:

Diabetic?

Camper Medications
A first-aid kit will always be present. It contains the following medications: Tylenol, Motrin, Cold Medication, and Antacids/Antidiarrheals.

May your child receive these medications if needed?

Comments:

IF YOUR CHILD NEEDS TO BRING ANY MEDICATION TO BE TAKEN DURING DAY CAMP HOURS, PLEASE FILL OUT THE INFORMATION BELOW. All medications (including aspirin and vitamins) must be checked in with the local coordinator upon arrival.
I give my permission for the Local Coordinator or designated church volunteer to keep and administer the following medications:

Medication

Dosage

How often?

Medication

Dosage

How often?

Any special information concerning this medication?

Parent or Guardian Signature (typed will act as signature)

Date

Personal Information
Please share any information to help us give your camper the best experience possible.

Has anything happened recently in your family or with friends that may affect your child's behavior while at camp? Any emotional upsets?

Is your child apprehensive about anything at camp?

Any other suggestions or special information for the counselor?

2023 Day Camp Health History Form - St. Johannes Lutheran Church

Description

Please Fix the Following