Camper Health Form 2025

Camper Health Form 2025

For Campers at Camp Pineshore Bible Camp. One form must be filled out for each camper.
Camper Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age on First Day of Camp*
Gender*

MaleFemale
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian(s) Info

With Legal Custody To Be Contacted First In Case of Illness or Injury
Name*

First NameLast Name
Relationship to Camper*
Preferred Phone Number*
Please enter a valid phone number.
2nd Phone Number
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Second Parent/Guardian or Emergency Contact

To be contacted in case of emergency
Name*

First NameLast Name
Relationship to Camper*
Preferred Phone Number*
Please enter a valid phone number.
2nd Phone Number
Please enter a valid phone number.
Email
example@example.com
Additional Contact

In Event Parent(s)/Guardian(s) Can't Be Reached
Name*

First NameLast Name
Relationship to Camper*
Preferred Phone Number*
Please enter a valid phone number.
2nd Phone #
Please enter a valid phone number.
Email
example@example.com

Diet/Nutrition
Check all those that apply*

Camper eats a regular, varied diet and is prepared to eat a variety of foods at camp.Camper is a vegetation of this type: Semi-vegetarian (no pork or beef)Camper is a vegetation of this type: Pesco (no pork, beef, or chicken)Camper is a vegetation of this type: Vegan (no meats, eggs, dairy)Camper is a vegetation of this type: Lacto-ovo (no pork, beef, chicken, seafood, or fish)Camper is lactose-intolerant.Camper has issues with foods containing gluten based ingredients.Camper has an anaphylactic reaction when this food is eaten
What are the food(s) that cause an anaphylactic reaction?*

Restrictions on Activities
Does your camper need certain restriction or adaptions for certain camp activities?*

I have reviewed the program and activities of the camp and feel the camper can participate WITHOUT restrictions.I have reviewed the program and activities of the camp and feel the camper can participate WITH the following restrictions or adaptions in place that I will write in the space provided below:
Restrictions and Adaptations*

Medical Insurance Info
Camper is covered by family medical/hospital insurance?*

YesNo
Insurance Company*
Policy Number*
Subscriber*
Insurance Company Phone Number*
Please upload a copy of your insurance card if appropriate, copy both sides of the card so information is readable.

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Medication(s)

Bring enough medication to last the entire week. Prescription medications MUST be in the original pharmacy containers with appropriate labels. Other over the counter drugs and preparations such as vitamins, allergy medications and other supplements MUST be in original container. All medication will be checked in and administered by the camp nurse.
Medications*

Camper WILL NOT take any daily medications while attending camp.Camper WILL take daily medications while at camp
Camper takes this number of medications daily*
Name of Medications 1*
Reason for Taking Medication 1*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Dose Needed
Date Started/Last Dose
Name of Medications 2*
Reason for Taking Medication 2*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Does Needed
Date Started/Last Dose
Name of Medication 3*
Reason for Taking Medication 3*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 4*
Reason for Taking Medication 4*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 5*
Reason for Taking Medication 5*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 6*
Reason for Taking Medication 6*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose
Name of Medications 7*
Reason for Taking Medication 7*
Dose given at Breakfast
Dose given at Evening Meal
Dose given at Bedtime
Other Doses Needed
Date Started/Last Dose

Additional Information on Medications
The following non-prescription medications are stocked in the Mobile Infirmary and can be requested from the Camp Nurse as needed.

• Acetaminophen (Tylenol)
• Ibuprofen (Motrin)
• Diphenhydramine (Benadryl)
• TUMS Antacid
• Generic Cough Drops
• Calamine Lotion
• Aloe and Sunscreen
• Neosporin Antibiotic Ointment and Cream
• Hydrocortisone Cream
Allergy and Asthma Information
A camper prescribed an epinephrine auto-injector for a known allergy or pre-existing medical condition
may self-administer and carry an epinephrine auto-injector with him or her at all times for the purposes
of self-administration if:
• The camper is capable of self-administration; and
• Both the health care consultant and camper’s parent/guardian have given written approval

A camper prescribed an epinephrine auto-injector for a known allergy or pre-existing medical condition may receive an epinephrine auto-injection from someone who may give injections within their scope of practice, or from a camp employee if:
• Both the health care consultant and camper’s parent/guardian have given written approval; and
• The employee has completed a training developed by the camp’s health care consultant in accordance with the requirements in 105 CMR 430.160.
Inhaler Use
A camper prescribed an inhaler for a known pre-existing medical condition may self-administer and carry the inhaler with him or her at all times for the purposes of self-administration if:
• The camper is capable of self-administration; and
• Both the health care consultant and camper’s parent/guardian have given written approval.
I have read the additional information on medications above.*

Yes

Mental and Emotional Health Information

Please answer all the questions below for your camper with yes and no. For any yes answers, please give more detail in the space provided.
Has your camper ever been treated for attention deficit disorder (ADD or ADHD)?*

YesNo
Please explain or provide more detail.*
Please explain or provide more detail.*
Has your camper ever been treated for emotional or behavioral difficulties or an eating disorder?*

YesNo
During the past year, has your camper seen a professional about any mental or emotional health concerns?*

YesNo
Please explain or provide more detail.*
Does your camper have a significant life event that continues to affect the camper's life? (Example: History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, and etc.)*

YesNo
Please explain or provide more detail.*

Physician Contacts
Name of Camper's Physician*

First NameLast Name
Office Number*
Please enter a valid phone number.
Name of Camper's Dentist

First NameLast Name
Office Number
Please enter a valid phone number.

Anything we have forgotten to ask?
Is there any additional information about the camper's health that you think important or that may affect the camper's ability to participate in camp program? Please Explain.

Camper Physical
Please upload a copy of your camper's physical. This physical must be done within 18 months of the camper starting camp. You must provide a camper physical to participate in camp.*

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Immunization Records
Immunization requirements for children attending camp follow the Massachusetts school immunization requirements, as outlined in the Massachusetts School Immunization Requirements table, which reflects the newest requirement: meningococcal vaccine (MenACWY) for students entering grades 7 and 11 (on or after the 16th birthday, in the latter case; see the tables that follow for further details). Children should meet the immunization requirements for the grade they will enter in the school year following their camp session. Children attending camp who are not yet school aged should follow the Childcare/Preschool immunization requirements included on the School Immunization Requirements table.

If you have any questions about vaccines please contact the MDPH Immunization Program at 888-658-2850 or 617-983-6800.
Please upload a copy of your camper up to date immunization records. If your camper has a medical exemption, please upload the doctor's note for the exemption, along with any other immunization records. If there is a religious exemption to any or all immunizations please upload a letter from the parent/guardian that states in writing that a vaccine conflicts with his/her sincerely held religious belief along with any other immunization records.*

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Parental Right to Request Copies of Camp Pineshore's Policies

Required by Mass. State Code: 105 CMR 430.157
Parents may request copies of Camp Pineshore's background check policies, health care policies, and discipline policies as well as procedures for filing grievances. Any requests can be sent to Camp Director Rev. David Jacoby at davidjacoby65@hotmail.com.

Bugs and Sun
I understand that outdoor exploration is part of Camp Pineshore and my child will be exposed to risks including but not limited to sun, ticks, and insects. I give permission to Camp Pineshore's staff to assist my child in re-applying sunscreen, insect repellant, and topical anti-itch cream. I understand that participants in overnight programs will be given instruction on how to check themselves for ticks and will be reminded by staff to do so. I am also responsible to do a complete check upon my child’s return home.
Signature*

Clear
Date*

MonthDayYear
Date
Relationship to Camper*

Permission and Waiver
I understand and certify that my camper's partipation in Camp Pineshore and its acitviities is complety voluntary, that I have familiarized myself with the camp's program and activities, and that I give my permission for my camper to partipate in these activities. I understand that these activities include Group Initiatives, Swiming, Boating/Canoeing, Hiking and/or other Sports/Games and I acknowledge that although Camp Pineshore has taken safety measures to reduce the risk of injury, Camp Pineshore can neither ensure nor guarantee that programs, equipment, premises, and/or activites will be free of hazards, accidents, and/or injuries. I hearby release and waive and claim against Camp Pineshore, Messiah Lutheran Church-Fitchburg-MA, the Lutheran Church Missouri Synod, their employees, directors, officers, volunteers, and servants, from any and all liablity arising from any illness, including but not limited to Covid-19, or injury suffer by my camper(s) during his/her/their actitvites at Camp Pineshore and at related off-site activities, and for any lost or stolen articles.

I further recognize and certify that I have instructed my camper in the imporance of knowing and abiding by the camp's rules, regulations, and procedures or the safety of camp participants. I hearby give permission for the use of photographs and/or video including my camper for camp or church publicity. I certify that I have the legal authority to register this camper.
Signature*

Clear
Date*

MonthDayYear
Date
Type a question

TransportationWaiver and Release of Liability
Transportation services to my child in conjunction with Camp Pineshore activities, I, on behalf of myself, my child, authorize Camp Pineshore and request that Camp Pineshore provide transportation services to my child in conjunction with camp activities, and hereby voluntarily release, waive, discharge, hold harmless, defend and indemnify Camp Pineshore and its owners, agents, officers and employees from and against any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise as a result of the providing of transportation services to my child in conjunction with camp activities including without limitation transportation to, from or during any camp activity. I specifically understand that I am releasing, discharging and waiving any claim or actions that I may have presently or in the future for the acts or other conduct by the owners, agents, officers or employees of Camp Pineshore. I HAVE READ THE ABOVE ‘WAIVER AND RELEASE’ AND BY SIGNING IT AGREE IT IS MY
INTENTION TO EXONERATE AND RELIEVE CAMP PINESHORE FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER ACT OR OMISSION.
Signature*

Clear
Date*

MonthDayYear
Date
Type a question

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 injections, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with the 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.
Signature*

Clear
Date of Signature*

MonthDayYear
Date
Relationship to Camper*
Should be Empty:

Camper Health Form 2025

Parent/Guardian(s) Info

Second Parent/Guardian or Emergency Contact

Additional Contact

Allergies

Diet/Nutrition

Restrictions on Activities

Medical Insurance Info

Medication(s)

Additional Information on Medications

Allergy and Asthma Information

Inhaler Use

General Physical History

Mental and Emotional Health Information

Physician Contacts

Anything we have forgotten to ask?

Camper Physical

Immunization Records

Parental Right to Request Copies of Camp Pineshore's Policies

Bugs and Sun

Permission and Waiver

TransportationWaiver and Release of Liability

Parent/Guardian Authorization for Health Care