Jccbuffalo.org

CAMP CENTERLAND
Date Received ______________________________ HEALTH FORM
Reviewed & Initialed Camp Nurse_______________ Reviewed & Initialed by Camp Director___________ PARENTS: PLEASE PRINT, COMPLETE AND SIGN
Camper’s Name: ________________________________ Birth Date: ___/___/___ Age: _____ Sex:  M  F Custodial Parent: ____________________________________________ Phone: _______________________ Home Address: __________________________________ City: _______________ State: ______ Zip: ______ Name of Dentist/Orthodontist: _____________________________________ Phone: _________ Child’s Physician: ______________________________________________ Phone: ________________ In case of emergency notify: (other than custodial parent) 1. Name: ___________________________ Phone: __________________ Relationship: ________________ 2. Name: ___________________________ Phone: _____ MEDICAL INSURANCE INFORMATION: Please attach a photo copy both sides of your insurance card
Insurance Carrier: __________________________________________________________________________________
I.D. Number: ____________________________________ Group Policy Number: _______________________________
List any other important insurance related information: _____________________________________________________
Is the participant covered by family members insurance?  Yes No
Name of insured: _____________________________________ Relationship to Participant: _______________________
OVER THE COUNTER MEDICATION CONSENT
Parent AND Physician authorization are required in order to administer ANY medication
The following non-prescription medications may be stocked in the camp Health Office and are used on an as needed
basis to manage illness and injury. Please check those that you approve use of.
 Acetaminophen (Tylenol)
Note: This form MUST be signed by your physician if you the parent or guardian, want the Medical Director to
administer anything prescription or non-prescription to your child while at camp. By your physician NOT signing this form,
you are indicating that your child is not to receive anything while at camp. This will insure that we ONLY dispense
medications ordered and/or agreed to by the child’s physician.
EMERGENCY MEDICAL CONSENT
In the event my child is injured or becomes ill, I hereby give permission to the Camp Director, Camp Medical Director,
Physician or the hospital selected by the Camp Director to hospitalize and secure proper medical treatment for my child,
including, but not limited to ordering injections, anesthesia and or surgery. I understand that I will be held responsible for
all out of camp medical treatments, costs and or medications as prescribed.

Signed: _________________________________
Signed: __________________________________

IMMUNIZATIONS: Please attach a copy of your child’s immunization records.

Health forms cannot be accepted without this information attached.
PHYSICIAN: PLEASE COMPLETE AND SIGN
HEALTH HISTORY: Please check all that apply
 Asthma

MEDICATION
Does your child require medication to be administered during camp?  Yes No If yes, list:
Medication: ___________________________
Dosage: __________________ Frequency: _____________ Medication: ___________________________
Dosage: __________________ Frequency: _____________
Possible Side Effects:
 See package insert for complete list of possible side effects (parents must supply)
AND/OR
 Additional side effects: ____________________________________________________________________________
What action should be taken if side effects are noted:
 Contact physician at the phone number provided  Other: (describe): ________________________________________________________________________________
Special Instructions:
 See package insert for complete list of special instructions (parents must supply)
AND/OR
 Additional special instructions: ______________________________________________________________________
ALLERGIES  No known allergies
Food Allergies: Please check all that apply
 Dairy
Describe reaction and management:____________________________________________________________________
_________________________________________________________________________________________________

Medication Allergies:
Describe reaction and management:____________________________________________________________________
_________________________________________________________________________________________________

Environmental Allergies: Please check all that apply
 Insect stings  Hay Fever
Describe reaction and management:____________________________________________________________________
_________________________________________________________________________________________________
Please list any activity restrictions: _____________________________________________________________________
Physical Exam: Must be within 1 year
Height: ____________ Weight: ____________ Blood Pressure: ____________ Date of last examination: ___________
PHYSICIAN’S STATEMENT
I have examined the patient herein and have reviewed the Health History. It is my opinion that this patient is physically
able to engage in camp activities, except as noted above.
Examining Physician’s Signature: _________________________________________ Phone: ___________________
Examining Physician’s Name: (Please Print) _________________________________
Physician’s Address: ________________________________ City _______________ State _________ Zip _________
Physician Stamp:

Source: http://www.jccbuffalo.org/healthform.pdf