YOUTH CAMP HEALTH HISTORY
CAMPER
(MDH-4768 12/2017)
Child's Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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EMERGENCY CONTACT INFORMATION:
Emergency Contact Parent or Legal Guardian
Phone
Email
example@example.com
2nd Emergency Contact Other than Parent Above
Phone
Primary Care Physician or other provider of medical care
Phone
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HEALTH INFORMATION:
Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?
Yes
No
If yes, Please Explain
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive?
Yes
No
If Yes, Please Explain
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IMMUNIZATION INFORMATION:
For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?
Yes
No
If Yes, Please List
For campers who reside outside the United States, a United States territory, or the District of Columbia, Please attach/submit record of vaccination or immunity on Department form MDH-896.
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Parent or Legal Guardians Signature
Date
/
Month
/
Day
Year
Date
MDH-4768 (12/2017)
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