Camper Health Form 120823

Camper's Health Form Physicals must be completed within 24 months of camp and submitted to the Camp Director two weeks prior to camp session. Sports physicals are acceptable IF the information provided mirrors what is asked on Part I. Immunization information is required. Part II of this form will still need to be completed.

Part I - For physician or nurse practitioner to complete and sign Note: This child is planning to attend a week-long resident camp away from his/her home and some distance from care. The camp will have a health supervisor who has at least completed an advanced first aid course. Your response to all these questions will help care for the child. Use the back of this form to record additional information.
Camper name
Birth date

MonthDayYear
Date
Past history of serious lacerations, injuries, or illnesses
Current conditions
To drugs (Penicillin, etc)
To food
Special dietary requirements
Other allergies
Attach an official certificate of immunization.
I have examined this camper and found him/her to be in satisfactory physical condition and capable of active participation in a regular camping program EXCEPT as follows
Signature of physician/nurse practitioner

Clear
Date

MonthDayYear
Date
Printed name of physician/nurse practitioner
Address
Phone
(See next page for Part II - Medication Administration)
Part II - Medication Administration
Camper name
Birth date

MonthDayYear
Date
Over the Counter Medications
Dosage Instructions
Over the counter medications NOT permitted for this camper
Parent Signature

Clear
Date

MonthDayYear
Date
Prescription Medications
Dosage Instructions
Name of physician/nurse practitioner verifying prescribed medications
Signature

Clear
Date

MonthDayYear
Date
Prescription medications brought to camp must be in original bottle with directions and camper's name on it. Children with asthma are required to bring their inhaler, also properly labeled.

12/8/23 Denver Church of Christ
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