(WINTER) JMC Health Form Camp Olympia 2025

  • Camp Olympia 2025 (Winter)

    Participant and Staff Health History

  • All information submitted on this form is reviewed by medical professionals and will remain confidential. Please complete and submit this form in its entirety.

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

  • Medical Insurance Information

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  • Immunization History

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    In the acceptance email that you received with the link to this form, you were advised to obtain the applicant’s immunization records from the applicant’s doctor. 

    AKHB highly recommends that the participants and staff attending the camp are vaccinated with the primary vaccine, booster, and bivalent COVID vaccine. However, these vaccinations and boosters are not required. 

    Please upload the immunization records by clicking on the “browse” button immediately below, selecting the immunization file from your computer or phone, and uploading the file. If you need to upload multiple files you may do so by clicking on the browse button a second time and uploading any additional files.

    If you need to upload multiple files you may do so by clicking on the browse button a second time and uploading any additional files.

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  • Health-Care Providers 

  • Format: (000) 000-0000.

  • Recommendations From Licensed Medical Personnel

  • In the acceptance email that you received containing the link to this form that you just completed, you should have also received a downloadable copy of the "Recommendations from Licensed Medical Personnel" form to be filled out by a licensed medical personnel.


    Please upload the “Recommendations from Licensed Medical Personnel” form, by clicking on the “browse” button immediately below, selecting the correct file from your computer or phone, and uploading the file.

    The "Recommendations from Licensed Medical Personnel" form can also be found by clicking here.

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  • Medical History

    Has/does the participant:

  • “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. JMC requires original pharmacy containers with labels which show your child’s name and how the medication should be given. Provide enough of each medication to last the entire time your child will be at camp.

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  • General Health Questions

    Has the applicant has/had:

  • Mental, Emotional, and Social Health

    Camp values mental well-being both in and outside of camp. We seek to provide a supportive and safe environment for leadership, staff, and participants to unleash their full potential, experience growth, and show up as their authentic selves. The following questions are intended for us to learn about the applicant and help us prepare a supportive and responsive environment for the applicant's needs. This information is being requested to best serve applicants during camp. This information will ultimately be de-identified/shredded after camp.

     

    Has the applicant:

  • Authorization for Health Care:


    I, the undersigned, hereby irrevocably give my consent to any and all medical, hospital, or surgical treatment, as well as treatment by a physician, that I may need as a result of an injury or accident; provided, however, nothing contained herein shall be deemed an obligation on any person or entity to provide any such medical, hospital, or surgical treatment or any such treatment by a physician.     I affirm that this health history is correct and accurately reflects the health status of the individual to whom it pertains. I have permission to participate in all camp activities except as noted by me and/or an examining physician. I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for me. 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 health record from providers who treat me and these providers may talk with the program’s staff about my health status. Healthcare professionals associated with JMC (Jubilee Monuments Corporation) have the right to evaluate my health upon arrival to the camp. I also acknowledge that if any information on this form is found to be incomplete or false, JMC retains the right to send me home, and I will be responsible for all costs incurred, including, but not limited to flights, transportation, and other miscellaneous expenses. Special Needs. Individuals needing special assistance (ADA, allergies, etc.) should notify the Organizer.

  • Parent/Guardian Authorization for Health Care:


    I, the undersigned, hereby irrevocably give my consent to any and all medical, hospital, or surgical treatment, as well as treatment by a physician, that I may need as a result of an injury or accident; provided, however, nothing contained herein shall be deemed an obligation on any person or entity to provide any such medical, hospital, or surgical treatment or any such treatment by a physician. I affirm that this health history is correct and accurately reflects the health status of the participant to whom it pertains. The participant has permission to participate in all camp activities except as noted by me and/or an examining physician. 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. Healthcare professionals associated with JMC (Jubilee Monuments Corporation) have the right to evaluate the participant's health upon arrival to the camp. I also acknowledge that if any information on this form is found to be incomplete or false, JMC retains the right to send the participant home, and I will be responsible for all costs incurred, including, but not limited to flights, transportation, and other miscellaneous expenses. Special Needs. Individuals needing special assistance (ADA, allergies, etc.) should notify the Organizer.

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  • Submission:

    Please submit your completed form using the “Submit” button

    When you press submit, wait to see a message that says “Thank You: Your submission has been received.” If you don’t see that message, please press the submit button again, as we have not received your information unless you see the “thank you” message.

     


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