WISCONSIN DISTRICT

WISCONSIN DISTRICT
UNITED PENTECOSTAL CHURCH INTERNATIONAL
Universal Camp Health Screening Form (Please Use For ALL Camps-Completed form will be kept on the campground for all camps)
PLEASE CHECK THE BOXES OF THE CAMPS YOU WILL BE ATTENDING:*

Kid's CampYouth Camp (Jr. High and/or Sr. High)Family CampSpanish CampMen's Camp
SECTION 1: CAMPER'S PERSONAL INFORMATION
Camper is:*

StaffCamperBoth, Camper at one and Staff at another
LAST Name of Camper*
FIRST Name of Camper*
Middle Name of Camper
Date of Birth of Camper*

MonthDayYear
Date
Age of Camper at Start of Camp Season*
Street Address of Camper*

Street Address

CityState / Province

Postal / Zip Code
Home/Cell Phone of Camper or parent*
Church City of Camper*
Pastor of Camper*
Pastor's Phone of Camper
Insurance Carrier of Camper*
If no insurance, please put NONE
Insurance Carrier Phone of Camper*
If no insurance, please put NONE
Policy # of Camper's Insurance*
If no insurance, please put NONE
SECTION 2: EMERGENCY CONTACT
Last Name of Emergency Contact*
First Name of Emergency Contact*
Relationship with Emergency Contact*
Phone Number of Emergency Contact*
Street Address of Emergency Contact*
Street Address of Emergency Contact
City, State, Zip of Emergency Contact*
SECTION 3: MEDICAL PERSONNEL MAY ADMINISTER THE FOLLOWING:
The following non-prescription medications are commonly stocked in camp Health Centers and are used on an as needed basis to manage illness and injury: Acetaminophen (Tylenol), Ibuprofen (Motrin), Pseudoephedrine (Sudafed), Dextromethorphan (Robitussin), Diphenhydramine (Benadryl), Loratadine (Claritin), Cough Drops, Topical Antibiotic Cream, Calamine Lotion, Hydrocortisone Cream, Laxatives (Milk of Magnesia), A&D Ointment, Antacid, Benzocaine Oral Gel, Eye Wash, Lidocaine Spray and Powder (Gold Bond).
Parent/Guardian, please check one of the following choices and list the above items the camper should NOT be given, if applicable:*

It is ok for the camper to have what is neededIt is NOT ok to give the camper the following
Parent/Guardian, please List Below any of the above items the camper should NOT be given:*
Non-prescription medications the camper should NOT be given
SECTION 4: ALLERGIES
I Have No Known Allergies
I Have Allergies To Foods (List In Next Box) Please inform the Chef
Please Note & Provide Information Regarding Previous Reactions to Foods
Foods
I Have Allergies To Medications (List In Next Box)
Please Note & Provide Information Regarding Previous Reactions to Medications
Medications
Other Allergies (List In Next Box)
Please Note & Provide Information Regarding Previous Reactions to Other Allergies
Other Allergies
SECTION 4: DIET & NUTRITION

The Camp Kitchen is Gluten-Free Friendly, NOT Gluten Free)
Eats a Regular Diet
Has a Medically Described Meal Plan Or Medical Dietary Restrictions
Please Describe what your Described Meal Plan or Medical Dietary Restrictions Are:
SECTION 6: THE CAMPER IS CURRENTLY UNDERGOING TREATMENT FOR THE FOLLOWING CONDITIONS
Condition

No Treatment(s)
Please describe if you have any special conditions and what treatments you are undergoing:
SECTION 7: OTHER TREATMENTS/THERAPIES TO BE CONTINUED AT CAMP
Treatments/Therapies

No Treatment(s)
Please Describe what treatments/therapies to be continued at camp if any:
Universal Camp Health Screening (continued)
Camper Name (Last)*
Camper's Last Name (This is at the top of the 2nd page in case they get separated)
Camper Name (First)*
Camper's First Name (This is at the top of the 2nd page in case they get separated)
SECTION 8: HEALTH HISTORY
Any Recent Exposure to Communicable Diseases?

Answer below
YesNo
If Yes, Explain what exposure to communicable diseases you have had.
Are immunizations current?

Answer below
YesNo
If No, Explain reason not current on immunizations.
Date of Last Tetanus Shot: (If never received, explain in box above)

MonthDayYear
Date of Last Tetanus Shot
If None, Explain why not current on tetanus shot:
SECTION 9:
Do you feel the camper will require limitations or restrictions to activities while at camp?

Answer below
NOYES
If "YES" Please describe your recommendations during camp regarding limitations or restrictions to activities while at camp
SECTION 10: MEDICATION*

NO DAILY MEDICATIONSWILL TAKE THE FOLLOWING PRESCRIBED MEDICATION(S) WHILE AT CAMP
MEDICATION #1 -DOSAGE-FREQUENCY-REASON
MEDICATION #2 -DOSAGE-FREQUENCY-REASON
MEDICATION #3 -DOSAGE-FREQUENCY-REASON
MEDICATION #4 -DOSAGE-FREQUENCY-REASON
MEDICATION #5 -DOSAGE-FREQUENCY-REASON
MEDICATION #6 -DOSAGE-FREQUENCY-REASON
MEDICATION #7 -DOSAGE-FREQUENCY-REASON
MEDICATION #8 -DOSAGE-FREQUENCY-REASON
SECTION 11: STAFF/PARENT/GUARDIAN SIGNATURE (REQUIRED)
This health history is correct so far as I know, and is up to date as of the last 90 days. The person herein described has permission to engage in all prescribed camp activities except as noted. Emergency Authorization: I hereby give permission to the medical personnel selected by the camp officials to order x-rays, routine tests and treatment for me or my child, as in the event I cannot be reached in an emergency. I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for me or my child as named above. I hereby give permission to transport me or my child for medical assistance. This form may be photocopied for use at camp. I understand that I am responsible for payment of all medical treatments received from non-camp sources. I also give permission for the camp medical staff to administer over-the-counter medications to my child that I have approved on page 1 of this form. I also give permission for my child to participate in all camp activities.
Signature*

Clear
Relationship to Camper*
Date*

MonthDayYear
Date
SECTION 12: ADDITIONAL NOTES
Should be Empty:

WISCONSIN DISTRICT

UNITED PENTECOSTAL CHURCH INTERNATIONAL

SECTION 1: CAMPER'S PERSONAL INFORMATION

SECTION 2: EMERGENCY CONTACT

SECTION 3: MEDICAL PERSONNEL MAY ADMINISTER THE FOLLOWING:

SECTION 4: ALLERGIES

SECTION 4: DIET & NUTRITION

SECTION 6: THE CAMPER IS CURRENTLY UNDERGOING TREATMENT FOR THE FOLLOWING CONDITIONS

SECTION 7: OTHER TREATMENTS/THERAPIES TO BE CONTINUED AT CAMP

Universal Camp Health Screening (continued)

SECTION 8: HEALTH HISTORY

Any Recent Exposure to Communicable Diseases?

Are immunizations current?

SECTION 9:

Do you feel the camper will require limitations or restrictions to activities while at camp?

SECTION 11: STAFF/PARENT/GUARDIAN SIGNATURE (REQUIRED)