Pleasant Bay Camp :: Camper Health Form

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First Name:

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Last Name:

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Address:

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City:

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State/Province:

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Zip/Postal Code:

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Email Address:

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Phone:

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What week(s) are you attending camp?

July 8
July 15
July 22
July 29
August 5
August 12 (ages 13-16)
August 19 (ages 14-18)

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Please enter your birthday in the order of month/day/year.

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Please enter your health insurance number.

Please indicate any other type of insurance coverage and provide the suitable information/number.

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Please write the name of your family doctor and their phone number.

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Who does the camper live with?

parents
foster parents
mother
father
guardian
grandparents

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Please enter the name of the parent/guardian?

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In case of emergency or illness please contact......(include name, phone and relationship please)

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If they are unavailable please contact...(include name, phone and relationship please)

* Will medication be required at camp? yes
no

If yes, please describe the medication, its purpose and how it is to be administered.

Does the camper have any of the following?

Food Restrictions or Issues
Heart Trouble
Asthma
Diabetes
Convulsions
Bedwetting
Nightmares/Sleepwalking
Headaches/Earaches/Sore Throat
Upset Stomach
Fainting
Past Operations
Serious Injury

Please comment if you have answered yes to any of the above.

Does the camper have any physical, mental or emotional weakness or disability, chronic condition or recent illness which the staff should be aware of that may require attention?

* Has the camper had any recent exposure to infectious disease? yes
no

* Does the camper have any allergies? yes
no

If the camper has allergies please list them, describe the type and severity of the reaction as well as the treatment given.

* Are the camper's immunizations up to date? yes
no

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Does the camper have any restrictions on swimming or other camp activities?

* By completing this form and submitting it, I authorize the camp nurse and/or director.. to secure medical advice and services as may be deemed necessary for the camper's health and safety.

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