Presbyterian Federal Chaplaincies

2022 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 Name Last Name
Child's Date of Birth

Month Day Year
Date
First Parent/Guardian Name

First Name Last Name
Second Parent/Guardian Name

First Name Last 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?

Yes No
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?
Doctor Information
Health Insurance
Do you have medical insurance

Yes No
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.
Please sign below

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2022 Childcare and Pre-Clubs Medical Form for Presbyterian Federal Chaplaincies

Allergies and Dietary Restrictions

Medications and Treatments

Immunizations

Health History

Health Insurance