Presbyterian Federal Chaplaincies

2024 Childcare and Pre-Clubs Medical Form for Presbyterian Federal Chaplaincies
General Information

We require medical information for each child in Childcare and Pre-Clubs. It is essential for the camp to have your child's current health information in order to be able to ensure the safety and well-being of campers during their time at camp.

Please use the form below to provide important contact and medical information
Name of Child

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
First Parent/Guardian Name

First NameLast Name
Second Parent/Guardian Name

First NameLast Name
First Parent/Guardian Phone Number
Please enter a valid phone number.
Second Parent/Guardian Phone Number
Please enter a valid phone number.
Emergency Contacts

First NameLast NamePhone Number
First NameLast NamePhone Number
Child's Last Medical Exam Date:
Allergies and Dietary Restrictions
Does your child require an EpiPen?

YesNo
If yes, please provide details about your child's anaphylaxis, including the date and description of the reaction. If your child requires an EpiPen, please alert your child's supervisor.
Medications and Treatments
Does your child take any medication on a regular basis? If so, please explain what medications your child takes regularly and why they are taken.
Immunizations
Please list the date of your child's most recent vaccination or booster, if any, for the following
If your child has not been fully immunized, please explain:
Health History
Has your child experienced, or is currently experiencing any of the following conditions?
Be sure to fully explain any conditions your child is currently experiencing.
Has your child been exposed to any communicable diseases within the last 3 months? If so, please explain what disease(s) your child has been exposed to, and when the exposure occurred. It is important to mention any signs of illness that camp staff should look out for.
Does your child have any restrictions on activity? Please explain what activities must be restricted and list any special accommodations that should be made.
If your child requires any special assistance while at camp, what might that be?
The following questions are an opportunity to provide information about your child's behavior or emotional well-being that would be helpful for our counselors to know.
What social considerations or preferences would assist our staff in creating a supportive environment for your child? How does your child typically communicate or express themselves, especially in social situations?
Would you like to tell us about any sensory sensitivities or preferences your child has (e.g., sensitivity to loud noises, preference for specific textures):
From your experience or other camp experiences for your child, would you like to tell us about any diagnosed conditions might your child have that our camp staff should be aware of. Please list strategies or accommodations that worked well for them.
Does your child have any other specific needs or requirements or is there anything else we should be aware of to ensure a positive camp experience?
Physician Information
Doctor Information
Health Insurance
Do you have medical insurance

YesNo
Medical Waiver

The above medical information is accurate. I understand that Montreat Conference Center does not carry medical insurance on my child. I give my permission for Montreat Conference Center to seek medical attention for my child should the need arise.
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2024 Childcare and Pre-Clubs Medical Form for Presbyterian Federal Chaplaincies

Allergies and Dietary Restrictions

Medications and Treatments

Immunizations

Health History

The following questions are an opportunity to provide information about your child's behavior or emotional well-being that would be helpful for our counselors to know.

Physician Information

Health Insurance