Camp Pinehurst Camper Medical Form

Camp Pinehurst Camper Medical Form

Please complete all sections to ensure your child’s safety and well-being during camp.
Camper Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Parent/Guardian Contacts
Parent/Guardian 1 Name

First NameLast Name
Parent/Guardian 2 Name

First NameLast Name
Relationship to Camper
Best Phone Number for Parent/Guardian 1
Please enter a valid phone number.Format: (000) 000-0000.
Best Phone Number for Parent/Guardian 2
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Emergency Contact (if parents can't be reached)
Name

First NameLast Name
Relationship to Camper
Best Phone Number for Emergency Contact
Please enter a valid phone number.Format: (000) 000-0000.
Medical Contacts
Pediatrician or Family Doctor

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dentist

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical History, Restrictions, or Allergies
Does the camper have any chronic medical conditions?
If yes, please describe the condition(s):
Does the camper have any allergies?
If yes, list all allergies (food, medication, environmental, etc.):
Does the camper take any medications?
If yes, list all medications and dosages:
The camp must be notified if this child has or has been exposed to any communicable disease within three weeks prior to camp.
Health Insurance Details
Insurance Provider
It would be best to provide us with a copy of your insurance card
Policy Number
Subscriber ID#
Subscriber's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Consent and Authorization
When the camp secures medical attention for my child, I grant permission to doctors to utilize medical tests and x-rays. In the case of an emergency, and I cannot be reached, I authorize doctors to immediately begin proper treatment including injections, anesthesia, and surgery.
Signature of Parent/Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Camp Pinehurst Camper Medical Form

Camper Information

Parent/Guardian Contacts

Emergency Contact (if parents can't be reached)

Medical Contacts

Medical History, Restrictions, or Allergies

The camp must be notified if this child has or has been exposed to any communicable disease within three weeks prior to camp.

Health Insurance Details

Consent and Authorization