Camper Health History 2022
This health history will be reviewed by our camp health supervisor and health staff, and information may be shared when needed (i.e. allergy information to her counselor).
Check the camp(s) your camper will be attending this summer. Choose all that apply.
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Camp Kettleford (Bedford, NH)
Camp Seawood (Portsmouth, NH)
Camp Twin Hills (Richmond, VT)
Camp Farnsworth (Thetford, VT) (Day or Resident)
Camper Full Name
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Camper Date of Birth (mm/dd/yyyy)
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Camper Age
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Parent/Guardian Name(s) and Phone Number
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Parent/Guardian Email (this is the email where we will send a copy of this health form.)
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example@example.com
Allergies
Camper allergy information is shared with all camp staff for the safety of your camper. List all food, drug, or environmental allergies, and their reaction and treatment. Be sure to list the allergen, and the reaction and treatment. Please also tell us non-allergic dietary needs.
Food Allergies: If there are none, type NONE
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Non-Allergic Dietary Needs: Please tell us any non-allergic dietary needs or restrictions for your camper(i.e. vegetarian, low fat milk only, gluten free, hates peas, etc.) If there are none, type NONE.
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Drug Allergies: If there are none, type NONE.
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Environmental Allergies: If there are none, type NONE.
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Medical History
This information is reviewed by GSGWM Outdoor Admin upon receipt, and reviewed by the camp Health Supervisor and Camp Director. Relevant information is shared when necessary with staff or health professionals.
Enter the Date of the camper's last health exam
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Month
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Day
Year
Date
Camper's sex assigned at birth:
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If your camper uses pronouns other than she/her; please tell us your camper's preferred pronouns:
All immunizations as required for school are up to date:
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Yes
No
Enter the Date of the camper's last tetanus shot/booster
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Month
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Day
Year
Date
Please choose the covid-19 vaccination status of your camper:
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My camper is not vaccinated for Covid-19
My camper is partially vaccinated for Covid-19
My camper is currently fully vaccinated for Covid-19
My camper will be fully vaccinated for Covid-19 at summer camp
If immunizations are not up to date, please upload a copy of immunization report or physicians explanation; or a notarized vaccination exemption form.
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Medical conditions: If any of these conditions apply, provide a date and pertinent information for our health care supervisor. In the past year, has your camper had: any physician ordered restriction to physical activity; an illness lasting more than 5 days; confirmed exposure to any contagious disease; chickenpox, measles, mumps, or mononucleosis; a serious injury requiring medical attention; a surgical operation or fracture. If none of these apply, type NONE.
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In the past two years, has your camper had a medical history of which camp needs to be aware? Ear infections; Bedwetting; Sleepwalking/Sleep disturbances; Nosebleeds; Asthma; Diabetes(Type I or II); Severe Menstrual Cramps; Physical or Mental Disability; Seizures/Epilepsy; Hypertension/heart disease; Bleeding/Clotting disorder; Musculoskeletal disorder; Auto or other immune disease; Other physical restrictions. If none of these apply, type NONE.
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Please describe if your camper has any restrictions to any typical camp activities, or activities as described in the camp guide or description. If there are no restrictions, type NONE.
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Please describe if your camper has any learning, social, development, psychological, or emotional considerations that might impact her camp experience (i.e. making friends, keeping track of belongings, reading swim rules, etc.)? If there are no cosiderations, type NONE.
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Please describe if your camper has special services in or out of school of which camp should be aware or that might impact her camp experience (i.e. Personal care assistant, health aide, counseling, etc.)? If there are no services, type NONE.
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Please describe any recent changes or unusual circumstances in your camper’s life or family that camp should be aware of or that could impact her camp experience (i.e. loss of a pet, sister heading to college, new sibling, etc.)? If there are no recent changes, type NONE.
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Camper Full Name
Camper Date of Birth (mm/dd/yyyy)
Camper Age
Medications: Over the Counter Medications
I hereby give permission for Girl Scouts of the Green and White Mountains to administer the over the counter medications I indicated below if the health supervisor or other designated staff member deems it necessary to treat headache, upset stomach, fever, menstrual cramps, or insect bites/stings, or treat minor scrapes or injuries. Dosages will be administered according to directions of the medication or as directed in camp standing orders
Indicate each medication you wish to allow to be given to your camper while at camp for mild symptoms. Giving permission means we may administer the medication without contacting you first.
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Aloe (topical)
Calamine Lotion (topical)
Sting Relief (topical)
Benadryl
Antiseptic Skin Cleaner (topical)
Triple Antibiotic (topical)
Pepto Bismol
Acetaminophen (Jr or adult)
Ibuprofen (Jr or adult)
Naproxen Sodium (Aleve)
I do not give permission for over-the-counter medications
Medications: Prescription Medications
Prescription Medications: All medications brought to camp by campers, including vitamins and over the counter medications, must be brought in original containers and be accompanied by a signed physician’s order (sometimes called medication permission form). This form must be obtained from the physician, and have the physician’s signature. For more information, see the Family Guide for camp.
My Camper will have prescription medication at camp
Permission to Carry Asthma Inhalers and Epinephrine Auto-Injectors: These medications must be accompanied by a signed physician’s order (sometimes called medication permission form) and specifically state that the camper has the skills and knowledge to safely possess and use the medication. For more information, see the Family Guide for camp.
My camper will need to carry her Asthma Inhaler and/or Epinephrine Auto-Injector at camp
Health Insurance Information
Health Insurance Carrier/Plan
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Health Insurance Policy/Group Number
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Authorization for Medical Treatment and Signature
By signing, I attest that this health history is complete and accurate. I know of no reasons why my camper should not participate in activities except as noted. I understand that if her health condition(s) or insurance should change, I will notify the camp. I hereby give permission to the medical personnel selected by the camp to provide routine health care, to treat minor injuries or illness as directed in the standing orders by a licensed physician, to administer medications, to order x-rays, routine tests, treatments, to release any records necessary for insurance purposed and to provide or arrange necessary related transportation for my camper. I hereby give permission to the physician selected by the camp to secure and administer proper treatment, including emergency services, transportation, anesthesia or surgery for my camper, and to release medical information to the camp director or her designee for purposed of treatment. I agree to be financially responsible for any treatment provided in accordance with this permission. I agree to indemnify the Girl Scouts of the Green and White Mountains (GSGWM) for any medical expenses incurred pursuant to this authorization and to hold GSGWM harmless with respect to medical care administered to my camper while in their custody. This completed form may be photocopied for trips out of camp.
Signature of Parent or Legal Guardian
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