Camp Shamineau Health Form

LEGACY CHRISTIAN ACADEMY
Student Name
Date of Birth

MonthDayYear
Date
Age
Weight
ParentGuardian Name
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Address
Name of Health Insurance
Policy
Physician
Clinic Name
Clinic/Physician Phone #
Format: (000) 000-0000.
Current Health Information: Please answer all that apply to the above student.
Asthma triggers
Current treatment
Diabetes - please describe insulin, snacks, and when to call you:
Special dietary regimen or food allergies, please describe:
Other allergies list
Does your child carry epinephrine?
Notes about epinephrine:
Seizures - list all medications and when used:
Activity restrictions, describe:
Sleep problems, please check:
Other conditions:
Date of last tetanus booster

MonthDayYear
Date
Please check off which over the counter medications you give permission for a Legacy Staff member to administer to your child if it is needed while on the trip. We will administer the medication dosage based on the student's weight.
Tylenol:
Ibuprofen:
Benadryl
Cough Drops
Parent Signature
Date

MonthDayYear
Date
Should be Empty:

LEGACY CHRISTIAN ACADEMY