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