Health and Consent Form for Summer Camp

Health and Consent Form for Summer Camp
We at the Camp would like to provide the best camping experience for all our campers. Thus, it is important that we make sure to be aware of each and every health concern of our campers during the camp by having the information requested in this form. We guarantee that the information acquired here will not be shared with any third party.

Pregnant and Post-Delivery Teens:

For teen moms who are 6 to 12 weeks post-delivery on camp date must be certified by a medical physician. Pregnant teens over 34 weeks are not allowed to attend camp.

Note:
- All information you submit through this form is protected by HIPAA privacy laws.
- This form is only good for this specific program or camp activity attendance. A new form must be completed for every camp registration.
Date

MonthDayYear
Date
Name of Camper

First NameLast Name
Date

MonthDayYear
Date
Gender

MaleFemale
Name of Parent/Guardian

First NameLast Name
Phone Number (Landline)
Please enter a valid phone number.
Phone Number (Mobile)
Please enter a valid phone number.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
Please enter a valid phone number.
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
In Case of Emergency
Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Mobile Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance
Is Camper covered by an Insurance Policy?

YesNo
Policy Number
Insurance Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Doctor Information
Name of Family Physician

First NameLast Name
Phone Number
Please enter a valid phone number.
Name of Family Dentist

First NameLast Name
Phone Number
Please enter a valid phone number.
Medical History
Camper is fit and healthy to participate in an active camp program

YesNo
Has Camper been exposed to any communicable disease in the past 6 months?

YesNo
If yes, please specify
Are all of Camper's vaccination/immunizations as required by the public school system is updated?

YesNo
Date of last Tetanus Shot

MonthDayYear
Date
Any previous hospitalizations/surgeries:
Any limitations to any activity as advised by a physician (i.e. hiking, etc.):
Medication

C O N S E N T

Medical Release:

The information I have provided is true and correct to the best of my knowledge. If in case the named person in case of an emergency could not be reached out, permission is granted to the Camp representative to make arrangements in securing proper treatment, including hospitalization, anesthesia, and other injections, x-rays, or any other operations that may be immediately be needed.

I hereby authorize to release reports necessary for insurance purposes for my camper above and likewise grant that the information found in this form may be copied for purposes that are deemed necessary for the Camp to ensure the camper's need for securing medical treatment.

I understand the Camp's responsibility to make every effort to contact the camper's parent or guardian. I further understand that in case I do not have medical insurance, I will be responsible to shoulder all the costs of the medical expenses.

Liability Release:

In consideration of being permitted to participate in any way in the activities at and to attend the Camp, I hereby release, waive, and discharge the Camp, its affiliates, agents, and employees from any and all claims resulting in personal injury, death, or property loss due to accident or illness arising from, but not limited to the activities and participation at the Camp. I understand that participation in activities at Camp carries with it certain inherent risks that cannot be avoided regardless of the safety measures placed to avoid injuries. I agree to indemnify and hold harmless the Camp, its affiliates, its officers, and employees, from any and all claims, damages, and liabilities arising from damage and/or injuries from my child's participation in the Camp's activities.

I hereby declare that I have carefully read the abovementioned waiver and release and acknowledge that I have read and understood the above information. I agree with its terms and conditions and after knowing the entirety of these facts and in consideration of the Camp's acceptance of the abovenamed camper's enrollment, I am signing this Health and Consent form freely and voluntarily to release of all liabilities to the greatest extent allowed by law.
Signature of Parent

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Name of Parent Signatory

First NameLast Name
Date Signed

MonthDayYear
Date
Should be Empty: