• 2025 Hoop Camp Medical Forms

  • Camper Information

  • Which session will the camper be attending?*
  • Which payment option did you choose?*
  • Have you completed the online scholarship application yet?
  • Camper's Date of Birth*
     / /

  • IN CASE OF EMERGENCY NOTIFY:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Primary Care & Health Insurance Information

  • Format: (000) 000-0000.
  • Is this camper covered by health insurance?*

  • Health Status Section

  • Health History (Past or Present)*
  • Does this camper have any allergies we should be aware of?*
  • Date of last Tetanus shot?*
     / /
  • This camper is healthy and may engage in all usual camp activities*
  • Any physical or behavioral conditions that may affect or limit full participation in basketball or swimming?*

  • Parent or Legal Guardian's Authorization For Emergency Care

  • Date*
     / /

  • Authorization For The Administration Of Over-the-counter (OTC) Medications

    ALL OVER THE COUNTER MEDICATION MUST BE IN THE ORIGINAL CONTAINER WITH THE CAMPER’S NAME ON THE BOTTLE. A PARENT’S SIGNATURE IS REQUIRED.
  • The camp nurse has my permission to give my son/daughter Over-the-counter (OTC) medicine/medicines for the treatment of a fever (100.0 degrees or higher), headaches, muscle strain, or hives/rash. You will be notified if the problem persists. (Please select at least one option)*
  • How many Over-the-counter (OTC) medications are you providing to be administered?*

  • OTC Medication #1 (please fill in the blanks below)
    The name of the OTC medication is *
    It is used to treat the following condition*
    The dosage to be given is *

  • OTC Medication #2 (please fill in the blanks below)
    The name of the OTC medication is *
    It is used to treat the following condition*
    The dosage to be given is *

  • OTC Medication #3 (please fill in the blanks below)
    The name of the OTC medication is *
    It is used to treat the following condition*
    The dosage to be given is *

  • Date*
     - -

  • Authorization For The Administration Of Prescription Medications

    All Prescription Medications Must Be In Original Containers And Labeled With Camper’s Name, Name Of Drug, Strength, Dosage, Frequency, and Authorized Prescriber Or Dentist’s Name

  • Prescription Medication #1 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #2 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #3 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #4 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #5 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #6 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #7 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #8 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #9 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Prescription Medication #10 Administration Information (please fill in the blanks below)
    The name of the drug is *
    It is used to treat the following condition*
    The dosage to be given is *
    The time of day medication is given: (please select all that apply)
                      *    
    Relevant Side Effects?      * .
    If you answered yes, then please specify:      

  • Date*
     / /
  • Does this individual need to carry and self-administer a life saving emergency medication or device.

  • Authorization/Approval For Self Administration Of Emergency Medication

  • PARENTS/GUARDIANS PLEASE READ: By signing this form you are giving permission for your child to administer lifesaving medications without adult or medical supervision of any kind.Do not sign this form unless the child has a life-threatening condition and self-administers his/her own medication. PARENTS/GUARDIANS PLEASE READ: Dosing instructions or any limitations,notes or comments, such as when these devices can or can’t be used, nullifies the document. 

  • As the parent/legal guardian of *, I consent to the following:

  • During his/her time at camp, the camper is permitted to carry and self-administer the following emergency medication/device.*

  • Summary of Maine Law on Self-Administration of Emergency Medications


    Recreational camps for children; emergency medication. A recreational camp for boys or girls must have a written policy authorizing campers to self-administer emergency medication, including, but not limited to, an asthma inhaler or an epinephrine pen.

    The written policy must include the following requirements:


    1. A camper who self-administers emergency medication must have the prior written approval of the camper's primary health care provider and the camper's parent or guardian;
    2. The camper's parent or guardian must submit written verification to the camp from the camper's primary health care provider confirming that the camper has the knowledge and the skills to safely self-administer
    the emergency medication in camp;
    3. The camp health staff must evaluate the camper's technique to ensure proper and effective use of the emergency medication in camp; and
    4. The emergency medication must be readily available to the camper.

  • Date*
     - -

  • **To be completed by Camp Nurse**

  • Date
     - -

  • Release Of Liability And Medical Coverage

  • Policies and Media Release

  • Click the links below to read the policy documents:


    REFUND POLICY

  • Should be Empty: