Medical Information
Are you at present time taking any medications?

Yes
Immunizations are current with Texas School & Child Care Requirements?*

YesNo
Medications

Please list all medications, dosages and times for each dose:
Medication
Dosage
Times
Medication
Dosage
Times
State Law requires all medications be placed in the First Aid Station. Please place medications in a zip lock bag while still in the original bottle, labeled with the camper's name, medicine, and church.
Do you have any allergies (including medications)? If yes, please explain
Date of last tetanus shot

MonthDayYear
Date

Recent serious injuries?*

YesNo
Recent surgery?*

YesNo
Chronic medical conditions?*

YesNo
If YES to any above, please describe

Family Physician
Physician Phone
Address
Insurance Provider
Insurance Policy
Medical Insurance Card Picture

It is recommended that you attach a photocopy of your medical insurance card.
Cancelof
Authorization
I give my permission to Camp Chaparral Baptist Assembly's staff and/or church or group responsible: Heritage to provide and authorize medical treatment that may be deemed necessary to insure the well-being of the named student/sponsor, Including the following checked items as needed: Acetaminophen, Ibuprofen, Benadryl, Antacid. I understand that every effort will be made to provide the safest environment possible at camp, but accidents can and do occur. I agree not to hold liable the sponsoring church, thecamp staff, or Camp Chaparral in the case of an unforeseen event during any of but not limited to any of the following activities; Paintball, Ropes Course, Lake, Inflatables, Swimming, Canoeing, Laser Tag or any event. These terms shall serve as a RELEASE AND ASSUMPTION OF RISK for all heirs, executors, administrators and family members. I, furthermore, hereby acknowledge, that I am aware that my child could potentially be exposed to various illnesses, including COVID-19, and I am willing to assume that risk. I agree not to hold Camp Chaparral liable for any damages related to such exposure. I also give permission to Camp Chaparral Baptist Assembly to use any photos/video of my child/myself taken while participating in camp activities for promotional materials and Chaparral website. I also understand that Camp Chaparral cannot be responsible for lost or broken items, and that unclaimed items will be donated to charity at the end of the summer.

***I also agree to check for head lice and bed bugs within 24 hours of attending camp.

***I certify that I will check my child to ensure he/she is not running a fever before sending them to Camp Chaparral**
Parent/Guardian Name*
Student/Sponsor Name*
Parent/Guardian/Sponsor Signature*

Clear
Date Signed*

MonthDayYear
Date
Parent/Guardian/Sponsor Name*
We (both camper and parent/guardian)/I have read and do understand the camp rules (over) and agree to abide by them while at Camp Chaparral. We understand that refusal to do SO could result in being sent home at our expense at the discretion of the camp director and/or camp administration.
Parent/Guardian Signature*

Clear
Date Parent/Guardian Signed

MonthDayYear
Date
Camper/Sponsor Signature*

Clear
Date Camper/Sponsor Signed

MonthDayYear
Date

Medication Administration Form
CAMP CHAPARRAL
- All medications brought to camp must be included on this form and given to the church leader who will give it to the Medical Staff of Camp Chaparral at camp check-in.
- All medications must be listed on this form and placed in a large Ziploc bag, along with this form.
- Prescription medication must be properly labeled, if dosage on the container is different than what is to be given, a doctor's note must accompany the prescription with current instructions.
- No medication will be given unless they are in original containers per Texas Department of State Health Services.
- Camp Chaparral Medical Staff request that you do not send over-the-counter medications (i.e. Tylenol, Ibuprofen, Benadryl, etc These types of medications can be provided by Camp Chaparral.
- If you have any questions, please contact the Camp Chaparral Medical Staff.
- This form must be signed by the parent.
Name
Age
Church Name
Church City
Camp Name
Camp Date

MonthDayYear
Date
As the parent or legal guardian of the above named child, I give my permission to the enlisted Camp Chaparral Medical Staff to administer as prescribed by law the listed below medication to my child.
Parent/Guardian Signature*

Clear
Date Signed*

MonthDayYear
Date
Print Parent/Guardian Name*
Contact Phone Number*
Dosage (tablet, capsule, (amount given) liquid, inhaler)

If necessary, make additional copies of this blank form in order to provide requested information for each medication.

Type a question

	Medication	Form(tablet, capsule, liquid, inhaler)	Dosage(amount given)	Frequency(how often)	Purpose	Comment(special instructions)
1
2
3
4
5
6
7
8
9
10

Should be Empty:

STUDENT/SPONSOR REGISTRATION/MEDICAL FORM

Registration Information

Medical Information

Medications

Authorization

Medication Administration Form

CAMP CHAPARRAL