Camp Hope Health History and Examination Form for New and Returning Campers

Camp Hope Health History and Examination Form for New and Returning Campers

To be completed and signed by a parent/guardian
Name of camper*

First NameLast Name
Camper date of birth*

MonthDayYear
Date
Camper Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Physician*

First NameLast Name
Physician Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physician Phone*
Please enter a valid phone number.
Does the camper have any medication, food, environmental or other allergies?*

YesNo
Allergies*

MedicationFoodOther
Medication Allergies*
Food Allergies*
Other Allergies*
List any dietary restrictions (if none please put n/a)*
List any activity restrictions (if none please put n/a)*

Health History*

	Current	History	Explanation of Current Status
A) Asthma
B) Diabetes
C) Frequent Colds
D) Pneumonia
E) Lung/Breathing Problems
F) Seasonal Allergies/Other
G) Ear Infections
H) Frequent Headaches
I) Serious Skin Problems
J) Gum Problems
K) Dental Problems
L) Hypertension
M) Heart/Circulatory Problems
N) Stomach/Digestive Problems
O) Kidney/Urinary Problems
P) Pica (eats inedible objects)
Q) Hepatitis B Carrier
R) Seizure Disorder***
None of the above

Seizure Information Form - for New and Returning Campers

To be completed and signed by a parent/guardian
Name of Camper*

First NameLast Name
Does your camper have a seizure disorder?*

YesNo
BY SIGNING BELOW I CONFIRM MY CAMPER DOES NOT HAVE A SEIZURE DISORDER*

Clear

I permit the Arc of Essex County staff to apply sunscreen to my camper:*

Yes - apply sunscreenNo - please do not apply sunscreen
This authorization covers the period in which the Camp Hope staff is providing care to the camper.*

Clear
Please DO NOT administer any sunscreen to camper*

Clear
Sunscreen Type(s)*

Seizure Information Form - for New and Returning Campers