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.
ALLERGIES: Please list allergy and describe reaction.
* If you are unable to scan and upload insurance card, please photocopy front & back of health insurance card and return to camp with physician signed camp health certificate*
To be Filled out and signed by Physician
Please download, print and have your physician complete and sign the camp health certificate. Once completed, please scan and email to firstname.lastname@example.org, bring with you to camp, or mail to Camp Strawderman, 2494 Dellinger Acres Road, Edinburg, VA 22824 before your arrival date.
CAMPER IMMUNIZATION RECORD
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.
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.