Camp Agape Health History Form

MEDICAL INSURANCE

*** Please bring a copy of your insurance card if appropriate; copy both sides of the card so information is readable. You can turn this in when you drop off your camper.
Is this camper covered by family medical/hospital insurance?*

Yes, this camper is covered by family medical/hospital insurance.No, this camper is not covered by family medical/hospital insurance.
Name of Insurance Company if applicable
Policy Number
Subscriber/Policy Holder's Name
Insurance Company Phone Number
PARENT/GUARDIAN AUTHORIZATION FOR HEALTH CARE:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.
Digital Signature of Legal Guardian
Name of Legal Guardian*

First NameLast Name
Date of Signature

MonthDayYear
Date
How are you related to the camper

MEDICATIONS

Please list all medications, even over-the-counter medications, that will be administered by our camp medical team or counselors. Please send ALL medication in its original container with the child's name and prescription label on it.
Will your child be taking medication while at camp?*

Yes, my child will need to take daily medication while attending camp.No, my child does not need to take any daily medication while attending camp.
If your child does not need to take medication during the week of camp, you can skip the next section about medication information.
Info of First Medication
Name of medication 1:blank
Reason for taking medication 1:   blank
Time of day medication 1 is taken:   blank
What amount or dosage of medication 1 is given each time?:   blank
Any special instructions about medication 1?: blank
Info of Second Medication
Name of medication 2:blank
Reason for taking medication 2:   blank
Time of day medication 2 is taken:   blank
What amount or dosage of medication 2 is given each time?:   blank
Any special instructions about medication 2?: blank
Info of Third Medication
Name of medication 3:blank
Reason for taking medication 3:   blank
Time of day medication 3 is taken:   blank
What amount or dosage of medication 3 is given each time?:   blank
Any special instructions about medication 3?: blank
Info of Fourth Medication
Name of medication 3:blank
Reason for taking medication 3:   blank
Time of day medication 3 is taken:   blank
What amount or dosage of medication 3 is given each time?:   blank
Any special instructions about medication 3?: blank

MENTAL, EMOTIONAL & SOCIAL HEALTH

Please let us know if your child has anxiety, depression, OCD, ASD, social struggles, etc. We have an awesome, exciting week packed with fun activities. In addition to being away from home and routines, our days can be long and hot. These environmental conditions can elevate some of the things listed above.
Check all that apply to your child. Give details in the box below.*

1. My child has been diagnosed or treated for attention deficit disorder (ADD) or attention deficit Hyperactivity disorder (ADHD).2. My child has been treated for emotional or behavioral difficulties or an eating disorder in the last 12 months.3. My child has seen a professional to address mental/emotional health concerns in the last 12 months.4. My child has had a significant life event that continues to affect my child's life. (History of abuse, death of a loved one, family change, addiction, adoption, foster care, new sibling, survived a disaster, recent move, other)5. My child does not have any mental health or emotional concerns at this time.
Please provide details about each item you checked in the list above. Provide the number of the item you checked with your explanation. If you have additional information about something that was not listed above, please include details about that as well. All of this information helps our camp staff better prepare and care for all of your child's needs throughout the week.
ADDITIONAL INFORMATION
Our goal is to help every child have the best camp experience possible. Understanding struggles that your child may have during a week away from home or with a large group of peers is extremely helpful. It is always better to be prepared for situations than to have to react to unexpected situations.

Please provide any additional information about your child's health or emotional well-being that you think may affect their experience at camp, or may be important for our camp staff to be aware of. (First time at camp/away from home, gets overstimulated/reacts to loud noises, etc.)
Additional information we should know about your child.
IMPORTANT! After you submit this form, you will need to download the Health Physical Form from the Camp Agape web page.

Your child's physician must complete and sign the Health Physical Form. You can turn in the form to our medical team when you drop your child off at camp.
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