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 Name Last Name
Camper Address *

Street Address

Street Address Line 2

City State

Zip Code
Name of Physician *

First Name Last Name
Physician Address *

Street Address

Street Address Line 2

City State

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

Yes No
Allergies *

Medication Food Other
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 Name Last Name
Does your camper have a seizure disorder? *

Yes No
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 sunscreen No - 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