This form must be filled out by the camper's parent or guardian. The Provider form must be filled out and signed by each camper's personal physician, physician's assistant or certified nurse practitioner, even if your child does not require regular medication. Camp Hickory Hill is located on a hillside and will be physically challenging if your child's mobility is limited or health is otherwise impaired. Please be certain your child is in good health and up to the physical demands upon arrival at camp. We will be unable to safely accommodate some types of medical conditions. Please contact the camp director if you have questions.

Please be advised that we are subject to New York State laws and require the EXACT information requested. Failure to document this information will result in delay of registration of your camper.

Please fax or email a current immunization record. (contact info at end of this form) Camper may bring a copy with them to registration.

Required Parent's Authorization: This health form is accurate and the camper herein described has permission to engage in all camp activities, except as noted on this form. In the event that I cannot be reached in an emergency, I hereby give permission to emergency room physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above. I also authorize the authorized camp health personnel to administer treatment as per standing order protocol and to administer any medications prescribed by my child's personal physician as listed on the Provider Health Form.

IMPORTANT! PLEASE READ:

Please submit HEALTH PROVIDER FORM to your child's pediatrician for their review and signature. Their signature is required whether your child has medications or not. It allows the camp nurse to give any first aid or other health care to your child in the event it is necessary. Typical school health assessment or sports forms are NOT acceptable, as they do not authorize general health care for your child. Please list ALL medications (including over the counter or nonprescription drugs) taken regularly. Bring enough medication to last the entire time at camp.

IMPORTANT!!

Keep ALL medication and supplements in the original and current packaging/bottle that identifies the prescribing physician, the name of the medication, the dosage, the frequency of administration and purpose. 

This form must be fully & accurately completed and submitted prior to the onset of camp.

Admin. Address: CAMP JUDAH 2444 N Main St., Warsaw, NY 14569

Email: campjudah@gmail.com

Regular Fax (except during week of camp): 585-786-8249

Fax during week of camp only: (June 29 – July 5, 2024): 585-687-4624