C2C Health Form
Please answer the following questions about your Camper's medical history and health status as best you can.
Camper's Name
*
First Name
Last Name
Health Care Provider
Please list current contact info for your child's pediatrician
Doctor's Name
*
Doctor's Phone Number
*
Please enter a valid phone number.
Health Insurance
Does your camper have health insurance?
*
Yes
No
If yes, please complete the following. If no, please continue to the next session.
Insurance Policy Holder's Name
First Name
Last Name
Health Insurance ID
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Relationship to camper
Insurance Carrier
Policy Number
Group Number
Health History
Please list any medical needs, conditions, or concerns that we should be made aware of:
Are there any activities that your child should be exempted from for health reasons? If yes, explain:
*
Does your camper have asthma?
*
Yes
No
Does your camper have diabetes?
*
Yes
No
Mental, Emotional, and Social Health
Has your camper been diagnosed with any mental, emotional, and/or social health conditions?
*
Has your camper experienced any significant family/life changes?
*
Dietary Restrictions/Allergies
Please list any of your child's dietary restrictions/food allergens. This way we can make sure we have appropriate food for their daily lunches!
Medications
Will your camper need to take any medications during their time at day camp?
*
Review & Sign
Please review this form before submitting. By signing below, you confirm that the information above is, to the best of your knowledge, accurate and up to date.
Parent/Guardian Print Name
*
First Name
Last Name
Parent/Guardian Signature
*
Submit
Should be Empty: