Online Health Questionnaire

PRIMARY CONTACT INFORMATION
Person responsible for providing medical information (parent or guardian) *

First NameLast Name
Relationship
i.e. Mother, Grandmother, etc.
Email*
This is the email address of the above person. It is very important that this email address is correct as we will follow up with important information regarding health form.
Phone Number*
Can we text this number?

YESNO
Camper's Name*

First NameLast Name
What program is your camper registered for?*

1st Year (June 15-21, 2025)2nd Year (June 15-21, 2025)3rd Year (July 12-18, 2025)
Choose one:*

FemaleMale
Camper's Birth Date*

MonthDayYear

IN CASE OF EMERGENCY
Contact #1 Name*

First NameLast Name
Relationship
i.e. Mother, Grandmother, etc.
Emergency Phone*
Can we text this number?*

YESNO
Contact #2 Name

First NameLast Name
Relationship
i.e. Mother, Grandmother, etc.
Emergency Phone
Can we text this number?

YESNO

ALLERGIES

Check all that applies to your camper
CAMPER HAS:*

NO KNOWN ALLERGIESA FOOD ALLERGIESA MEDICINE ALLERGIESENVIRONMENTAL ALLERGIES (Insect stings, hay fever, etc.)OTHER ALLERGIES
What food allergies?
Please explain in detail
What medicine (s) is your camper allergic to?
Please explain in detail
What environmental allergies?
Please explain in detail
What other allergies does your camper have?
Please explain in detail
Does your camper carry an EPIPEN® for their allergies?

YESNO
Do they know how to administer the EPIPEN®?

YESNO

DIET
Please Check all that apply*

This camper eats a regular dietThis camper eats a regular vegetarian dietThis camper is lactose intolerantThis camper is gluten intolerantOTHER Restrictions
Please share any important information we need to know about their diet restrictions:

RESTRICTIONS

The Camp Wildwood program entails participating in various physical activities in an outdoor setting, which may involve exposure to hot weather conditions. The program also includes some light hiking in hilly terrain. It is important to note that these physical requirements may be similar to the stresses one may experience in a high school Physical Education (PE) class. Therefore, participants should be prepared to engage in physical exertion and be in reasonably good health to fully enjoy and participate in the camp activities.
Please choose one of the following:*

I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations.
Please list restrictions and/or adaptations:

MEDICATION
Please Choose ONE:*

This camper will not take any daily medications while attending camp.This camper will take the following daily prescription medication(s) while at camp:
List any medication taken regularly:
Please include the name of medicine, dosage, reason for taken it
NON-PRESCRIPTION MEDICATIONS

The following non-prescription medications may be stocked by our Camp Nurse and are used on an as-needed basis to manage illness and injury.
- Acetaminophen (Tylenol)
- Phenylephrine decongestant (Sudafed PE)
- Antihistamine/allergy medicine
- Diphenhydramine antihistamine/allergy medicine (Benadryl)
- Sore throat spray
- Calamine lotion
- Laxatives for constipation (Ex-Lax)
- Ibuprofen (Advil, Motrin)
- Pseudoephedrine decongestant (Sudafed)
- Guaifenesin cough syrup (Robitussin)
- Dextromethorphan cough syrup (Robitussin DM)
- Generic cough drops
- Antibiotic cream
- Aloe
- Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
Is there any medication listed above that your camper should avoid taking?*

My camper has no restrictions to the medication listed above.My camper should not be given:

MENTAL, EMOTIONAL, and SOCIAL HEALTH

Select “Yes” or “No” for each statement. If you select yes, please provide explanation below:*

	NO	YES
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?
3. During the past 12 months, seen a professional to address mental/emotional health concerns?
4. Had a significant life event that continues to affect the camper’s life?

DETAILED EXPLANTION (if needed)

OTHER MEDICAL CONCERNS

If there are any other medical concerns, regardless of how minor they may seem, please provide that information. This will greatly assist in ensuring your camper has the best possible experience during their stay at camp.
DETAILED EXPLANTION

MEDICAL INSURANCE INFO
This camper is covered by family medical/hospital insurance*

YESNO
SELF-INSURED DISCLAIMER (Initialize at the bottom):

IF YOU ARE SELF-INSURED, PLEASE READ AND ACCEPT THESE TERMS: In consideration for Camp Wildwood of South Carolina. Permitting THE ABOVE CAMPER, a minor, to participate in the Camp Wildwood Program (“Camp”), including all of the physical activities involved therewith AND in consideration for the Camp Wildwood Program, agreeing to waive its requirement that all Camp participants be insured under private insurance plans, Camper, by and through Camper’s parent(s)/guardian(s), hereby remises, releases and forever discharges the Camp Wildwood Program, as well as its affiliates, successors, assigns, representatives, sponsors and employees, from any and all actions causes of action, claims demands, and liabilities for, upon, or by reason of any damage, loss or injury to any person or to any property relating to Camper’s participation in Camp and all activities pertaining thereto. Camper, by and through Camper’s parent(s)/guardian(s), further agrees to indemnify and hold forever harmless the Camp Wildwood Program, against loss from any further claims, demands or actions arising from Camper’s aforestated Camp participation that may hereafter be make or brought against the Camp Wildwood Program. Initial
Name of Insurance Company:
Policy Number:
Name policy is under

Parent/Guardian Authorization for Health Care

This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

I agree with the Parent/Guardian Authorization for Health Care.

Initials Date

HEALTH FORM AND COPY OF INSURANCE CARD

After you submit this form, we will promptly reach out to you through the email address you provided. We will provide you with clear instructions on how to upload/submit the last two items required: a copy of your current health form and, if applicable, a copy of your insurance card.

Thank you for taking the time to provide this important information!
Email address to send instructions to:*
example@example.com
Should be Empty:

	NO	YES	EXPLAIN IF YES
1. Ever been hospitalized?
2. Ever had surgery?
3. Have recurrent/chronic illnesses?
4. Had a recent infectious disease?
5. Had a recent injury?
6. Had asthma/wheezing/shortness of breath?
7. Have diabetes?
8. Had seizures?
9. Had fainting or dizziness?
10. Passed out/had chest pain during exercise?
11. Had mononucleosis (“mono”) during the past 12 months?
12. Have problems with falling asleep/sleepwalking?
13. Ever had back/joint problems?
14. Have problems with diarrhea/constipation?
15. Have any skin problems?

MEDICAL INSURANCE INFO

HEALTH FORM AND COPY OF INSURANCE CARD