2022 Camp Registration NEOLA/MUP Camps

Health History for (Participant name) *

Date of Last Physical Exam *

Date

Date of Last Tetanus *

Date

Insurance Information: Is the participant covered by medical /hospital insurance *

Yes No

If so, list carrier or plan name

Policy/Group #

Physician

Orthodontist

Phone

List Allergies

Include medicines, food, insect stings or bites, hay fever, asthma, animal, etc.

Describe reaction and management of reaction If more space is needed, please attach an additional sheet

Please describe any special dietary needs below. If additional space is needed, please attach an additional sheet. *

This participant eats a regular diet. This participant eats vegetarian diet. This participant has special food needs

Special Food Needs Description

MEDICATIONS BEING TAKEN Please list all medication (including over-the-counter or non-prescription drugs) Bring enough medication to last entire camp/event. All medication must be in the original package that identifies the patient, prescribing physician (if prescription drug), name of the medicine, dosage and frequency of administration. If more space is needed, please attach an additional sheet.

Name of medication

When Given and Reason for taking medication

Camper Height *

Camper Weight *

Is there anything we need to know regarding gender identity? *

Yes No

If yes please let us know.

General Health: Check YES or NO for each statement. Please explain YES answers below, noting the number of the question, attach an additional sheet if needed.

For travel outside country, please name countries visited.

The Participant Has/Has Had/ or Does Have:

1.A recent injury, illness or infectious disease? *

Yes No

2.A chronic or recurring illness/condition? *

Yes No

3.Ever been hospitalized? *

Yes No

4.Ever had surgery? *

Yes No

5.Ever had a head injury? *

Yes No

6.Had fainting or dizziness? *

Yes No

7.Ever had seizures or convulsions? *

Yes No

8.Ever passed out/had chest pain during or after exercise? *

Yes No

9. Have diabetes? *

Yes No

10. Have asthma/wheezing/shortness of breath? *

Yes No

11. Ever had back/joint problems? *

Yes No

12. Have any skin problems (e.g. itching, rash, acne)? *

Yes No

13. Had mononucleosis ("mono") in the past 12 months? *

Yes No

14. Had problems with diarrhea/constipation? *

Yes No

15. Have problems with falling asleep/sleepwalking? *

Yes No

16. If female, have problems with periods/menstruation? *

Yes No

17. Have a history of bedwetting? *

Yes No

18. Wear glasses, contacts, or protective eyewear? *

Yes No

19. Traveled outside the country in the past 9 months? *

Yes No

If "Yes" to any question: Please Give Question Number and Detail

Mental, Emotional and Social Health Check YES or NO for each statement.

Please explain YES answers below, noting the number of the question, attach an additional sheet if needed.

Has the participant:

1.Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? *

Yes No

2.Ever been treated for emotional or behavioral difficulties or an eating disorder? *

Yes No

3.During the past 12 months, seen a professional to address mental/emotional health concerns? *

Yes No

4.Had a significant life event that continues to affect the camper's life? (history of abuse, death of a loved one, family change adoption, foster care, new sibling, survived a disaster, other. ) *

Yes No

If "Yes" to any question: Please Give Question Number and Detail

What have we forgotten to ask? Use this space to provide any additional information about the participant's health or behavior that you think importantor that may affect his/her ability to participate fully in the camp/event.

If insured please provide a front and and back picture of insurance card

File Upload

Type yes or no to say if vaccinated for Covid 19. If yes please provide picture of vaccination card. NOT BEING VACINATED WILL NOT KEEP YOU FROM COMING TO CAMP!

File Upload

If part of DOC or MUP congregations, please let your church know you registered. If you have been invited by a friend, please let that friend's church know you registered.

A Director's Letter and Packing List will be sent a Month Before Camp.

Ok there is one more form to fill out. Yup, you guessed it. It's about money. But before you get there, go get your camper. This part is for them.

Got them? Alright, Click "Register"