• This is the GREEN form

  • CAMPER HEALTH HISTORY FORM

  • Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health & Association of Camp Nurses
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  • Mail this form to the address below by (date)

  • Mail or bring this and the other forms to your sponsoring Elks Lodge.

  • To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed.

  • 1) Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy.

  • Camper Home Address:

  • Parent/guardian with legal custody to be contacted in case of illness or injury:
  • Format: (000) 000-0000.
  • Second parent/guardian or other emergency contact:
  • Format: (000) 000-0000.
  • Additional contact in event parent(s)/guardian(s) can not be reached:
  • Format: (000) 000-0000.

  • Medical Insurance Information:

  • Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
  • Format: (000) 000-0000.

  • 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.
  • Clear
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  • If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.
  • Page 1/4

  • CAMPER HEALTH HISTORY FORM 1

  • This is the GREEN form
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  • Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
  • Rows
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  • If your camper has not been fully immunized, please sign the following statement I understand and accept the risks to my child from not being fully immunized.
  • Clear
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  • "Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper's name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.

  • Rows
  • The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Camp staff has my permission to administer the following non-prescription medications to my child. Cross out those the camper should not be given.
    Acetaminophen (Tylenol)
    Phenylephrine decongestant (Sudafed PE)
    Antihistamine/allergy medicine
    Diphenhydramine antihistamine/allergy medicine (Benadryl)
    Sore throat spray
    Lice shampoo or cream (Nix or Elimite)
    Calamine lotion
    Laxatives for constipation (Ex-Lax)
    Ibuprofen (Advil, Motrin)
    Pseudoephedrine decongestant (Sudafed)
    Guaifenesin cough syrup (Robitussin)
    Dextromethorphan cough syrup (Robitussin DM)
    Generic cough drops
    Antibiotic cream
    Aloe
    Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)
  • Copyright 2008 by American Camping Association, Inc.
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  • Rev. 1/2007 LEE/EAW

  • CAMPER HEALTH HISTORY FORM 1

  • Camper Name:
  • Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
  • Birth Date:
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  • This is the GREEN form

  • General Health History: Check "Yes" or "No" for each statement. Explain "Yes" answers below.

  • Has/does the camper:

  • Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement

  • Has the camper:

  • Health-Care Providers:

  • Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records.
  • Copyright 2008 by American Camping Association, Inc.
  • Page 3/4
  • Rev. 1/2007 LEE/EAW

  • CAMPER HEALTH HISTORY FORM 1

  • This is the GREEN form
  • Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses
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  • Individual Health Record (For Camp Use Only)

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  • Screening has been conducted according to camp protocol and significant findings noted as follows:
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  • Copyright 2008 by American Camping Association, Inc.
  • Page 4/4
  • Rev. 1/2007 LEE/EAW
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  • Should be Empty: