Medical Forms

Camper Medical Form
Parent/Guardian Name*

First NameLast Name
Camper Name*

First NameLast Name
Do you have any medical conditions that we should be aware of?*
Do you have any food or other allergies that we should be aware of?*
Do you have any mental health issues that we should be aware of?*
Do we have your authorization to administer over-the-counter medication to your camper?*

YesNo
Will your camper bring prescribed medication from home?*

YesNo
What medication(s) does your camper take?*
Please list each on a new line. If not applicable, please write N/A.
What is the dosage of the medication(s)/tablet(s)?*
Please list each on a new line, so that it matches previous answers. If not applicable, please write N/A.
How many tablets does your camper take at a time?*
Please list each on a new line, so that it matches previous answers. If not applicable, please write N/A.
At what time(s) does your camper take their medication?*
Please list each on a new line, so that it matches previous answers. If not applicable, please write N/A.
Please note anything specific that we need to know in order to administer the medication(s)?
Ex Takes with meal, camper can self-advocate for PRNs, etc.
Would you like to speak to our team about any medical concerns ahead of camp?*

YesNo
Please sign below that we have your written authorization to administer the medication(s).
Parent/Guardian Signature*
Date*

MonthDayYear
Date
Camper Emergency Contact

Please list the person we should contact to make health decisions for the camper.
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please describe camper's relationship to Emergency Contact.*
Please read the alternative statements below and select the one you choose.*

If my child needs medical attention, it is my wish that the Emergency Contact is contacted before any medical procedures are taken on my child, unless immediate treatment is necessary to save my child's life or to prevent permanent injury. I accept responsibility for all costs related to such treatment.If my child needs medical treatment, it is my wish that the treatment is started while efforts are being made to contact the Emergency Contact. So that treatment is not delayed, I consent to any medical procedures, on the understanding that efforts to contact the Emergency Contact will continue to be made. I accept responsibility for all costs related to such treatment.
Parent/Guardian Signature*
Date*

MonthDayYear
Date
Should be Empty:

Camper Medical Form

Camper Emergency Contact