Camp Strawderman Medical Form

Camp Strawderman Medical Form
Name of Camper*

First NameLast Name
Date of birth*

MonthDayYear
Date
Parent Phone Number*

Area CodePhone Number
Parent Email*
example@example.com
Alternate phone Number*

Area CodePhone Number
In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for my child.*
Signature*

Clear

MEDICATIONS: Please list ALL medications including vitamins, over the counter medications, supplements, etc. If you anticipate your daughter to require regular dosing of over the counter medication, please send an adequate supply to camp with your daughter.
1. Name of medication, dosage and time taken
2. Name of medication, dosage and time taken
3. Name of medication, dosage and time taken
4. Name of medication, dosage and time taken
5. Name of medication, dosage and time taken
ALLERGIES: Please list allergy and describe reaction.
Medication Allergy
Seasonal/Environmental Allergies
Diet/Nutrition: This camper:

Eats a regular dietIs lactose intolerantIs gluten intolerant
Other (please explain)

Camp Strawderman

Health Certificate

To be Filled out and signed by Physician

Your physician must complete and sign the camp health certificate below. You will need to print a copy to take with you to the doctor.

To PRINT on a PC: Download and print.

To PRINT on a MAC: Copy and Paste the text of the form below onto a Word or Google Doc, then print as normal to your printer.

If you are unable to print this portion of the form, please click on the link below:

https://campstrawderman.com/wp-content/uploads/2022/06/camp-health-cert.pdf

Once completed, please scan and email to kcosgrove@campstrawderman.com by JUNE 1, 2023
CAMPER IMMUNIZATION RECORD
Please attach your camper's current immunization record or bring the updated record with you to camp

Browse Files

Cancelof

PARENT AUTHORIZATION & PERMISSION TO TREAT:

I certify that this Health Certificate and the Camper's medical history are correct and complete to the best of my knowledge. The Camper herein named has permission to engage in all camp activities except as noted by parent/guardian or physician.

I hereby give permission to the camp to provide, seek, and consent to routine health care, including, but not limited to, first aid and symptomatic treatments for minor conditions, including over the counter medications, as limited herein, administration of prescribed medications, and emergency care for my child as may be necessary, including, but lim not limited to, x-rays, routine tests and treatment, and/or hospitalization. I also give permission for the camp to arrange related transportation. I agree to the release of any records necessary for treatment, referral, billing or insurance purposes.

It is my intention that the camp be treated as acting in loco parentis if the Camper herein named is a minor. Further, it is my intention that the appropriate representatives of the camp be treated as "personal representatives" for the purposes of disclosing protected health information pursuant to the privacy regulations of the Health Information Portability and Accountabiity Act (HIPAA). I hereby agree that I have disclosed to camp representatives, as necessary: (I) all relevant information to the Camper's ability to participate in camp activities, (II) all relevant information regarding the Camper's health history and (III) all information necessary to keep me informed of my child's health status.
Today's date*

MonthDayYear
Date
Name of parent/guardian*

First NameLast Name
Signature of parent/guardian*

Clear
Should be Empty: