Friends Youth Camp Health Forms

Friends Youth Camp Student Health Form
All students and adults are required to have a completed and submitted health form, photo release, and code of conduct prior to arriving at Friends Youth Camp.
Church Information

Please provide the following information regarding the church your camper attends.
Church Name
Student Information
Student Name

First NameLast Name
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Male/Female
Student Age
Last 4 digits of Student's Social Security Number
This is needed in case we have to take your student to the hospital.
Shirt Size
Student Medical Information

Please complete all sections accurately
Student Birthday

MonthDayYear
Date
Is the student covered by family medical insurance?
Insurance Company Name
Name of primary insurance holder
Insurance ID/coverage number
Food Allergies

This section is for food allergies. Please list any applicable. Note: There is a later section for dietary restrictions, such as vegan/vegetarian.
Does your student have food allergies?
Food Allergy #1
Food Allergy #1 Details
Food Allergy #2
Food Allergy #2 Details
Food Allergy #3
Food Allergy #3 Details
Food Allergy #4
Food Allergy #4 Details
Food Allergy #5
Food Allergy #5 Details
Does your student have dietary restrictions? (Vegan, vegetarian, etc)
Dietary Restriction #1.
Dietary Restriction #2.
Dietary Restriction #3.
Dietary Restriction #4.
Dietary Restriction #5.
Seasonal/Other Allergies

Please list any allergies the Camp Nurse should be aware of.
Seasonal/Other Allergies?
Allergen #1
Allergen #1 Details
Allergen #2
Allergen #2 Details
Allergen #3
Allergen #3 Details
Allergen #4
Allergen #4 Details
Allergen #5
Allergen #5 Details
Medication
IMPORTANT

All medication MUST be in original container/bottle.

Daily sorters/pill keepers are NOT permitted.
If your child must take any medication, carefully read the medication instructions below.

Medication WILL NOT be administered unless all of the instructions are properly followed.

It is necessary that the school and camp authorities know you child's physical and mental condition.

If you have any doubt that your child is in good health, have a physician examine your child and forward the report to the camp.

Medication

A. If your child must take any medication, send medicine in the ORIGINAL CONTAINER. Daily sorters/pill keepers are not permittted.

B. PRESCRIPTION MEDICATIONS must be accompanied by a pharmacy label containing the RX number, the name of the medication, and dosage, directions for administration, and the child's name.

C. NON-PRESCRIPTION MEDICATIONS must be in their original containers, clearly labeled with the child's name, name of the medication, and directions for its use.

D. Medicine lying loose in sandwich bags or other containers will not be administered.

E. Your child will not be allowed to keep any medications in the dormitory (Inhalers/Epi-Pens permitted).
Due to program scheduling, medications are given at meal times, then at the end of programming each night.

Times are as follows:

7:30 AM

12:00 PM

5:30 PM

10:30 PM
Does your student take medication regularly that they will take at camp ?
Medication #1 Name
Medication #1 Details
Medication #2 Name
Medication #2 Details
Medication #3 Name
Medication #3 Details
Medication #4 Name
Medication #4 Details
Medication #5 Name
Medication #5 Details
Medication #6 Name
Medication #6 Details
Medication #7 Name
Medication #7 Details
Medication #8 Name
Medication #8 Details
Medication #9 Name
Medication #9 Details
Medication #10 Name
Medication #10 Details
IMPORTANT

If your child has been diagnosed with asthma by a physician and has medication including tablets, nebulizers, or inhalers, they MUST bring such treatment with them to camp or they will not be allowed to stay at camp!

If your child has an inhaler, they must keep it with them at ALL TIMES during camp!

If your child requires an epi-pen, they must keep it with them at ALL TIMES!
Does your child have an Epi-Pen?
Has your child ever been diagnosed with asthma by a medical professional?
Does your child have any other significant health history (heart condition, diabetes, any injury) or does the camper have any restrictions/medical conditions that the nurse needs to be aware of?
If yes, please explain:
I give permission for the Camp Nurse to dispense "as needed" over the counter medication to my child
Medication Allergies

Please list any known medication allergies and reactions.
Does your child have any medication allergies?
Medication Allergy #1
Medication Name
Medication Allergy #1 Details
Medication Allergy #2
Medication Name
Medication Allergy #2 Details
Medication Allergy #3
Medication Name
Medication Allergy #3 Details
Medication Allergy #4
Medication Name
Medication Allergy #4 Details
Medication Allergy #5
Medication Name
Medication Allergy #5 Details
Emergency Contacts
Parent/Guardian #1 Name

First NameLast Name
Parent/Guardian #1 Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student
Parent/Guardian #2 Name

First NameLast Name
Parent/Guardian #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Student
Alternate Emergency Contact #1

First NameLast Name
Alternate Emergency Contact #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Emergency Contact #1 Relationship to Student
Alternate Emergency Contact #2

First NameLast Name
Alternate Emergency Contact #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Emergency Contact #2 Relationship to Student
Consent to Treat/Medical Release
I hereby give permission for emergency treatment of my child in case of accident or illness, and for normal treatment during the program. I realize that Friends Youth Camp will make every effort to contact, first the legal guardians, followed by the person to notify in case of emergency. If neither one can be reached, I hereby give permission to the medical personnel selected by the program director and/or assigned staff member to order routine tests, X-rays, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation. I also give permission to the physician selected by the program director and/or assigned member to secure and administer treatment, including hospitalization, for the person named above. I understand that by signing below I have read and understand the above statements.
Friends Youth Camp Code of Conduct
Friends student: Please read the following, Code of Conduct. If you agree with and are willing to comply with all the expectations of the Code of Conduct and Friends Youth camp, please sign at the bottom of the page.

Parent or Guardian: Please read the following, Code of Conduct. Please sign the bottom of this form to show your intent to support the implementation of this Code of Conduct regarding your child.

As a student attending Friends Youth Camp, I understand that:
- I will conduct myself with respect towards other campers, advisors, and staff, so that I myself may be respected.
- I will conduct myself in a way that will not disrupt the camp program and other campers. Camp reserves the right to amend housing accommodations to maintain a quality camp program and camper experience.
- I will be expected to participate in all aspects of the camp program and follow the daily camp schedule.
- If parental permission is granted on the Health and Registration Form, I can use the swimming area, watercraft, and high ropes at those times provided in the camp schedule. Permission from the supervising instructor will be necessary.
- I am personally responsible for any athletic equipment I use, and I will pay for any loss or damage.
- I agree that I am not to have or use any form of tobacco, vape, alcoholic beverages, drugs, or fireworks while at Friends Youth Camp.
Failure to meet these standards will result in these steps:
- I will call my parents/guardians and report any conduct not in compliance with these guidelines.
- At the Director's discretion, this may also result in parent/guardian arranging transportation home.
Signature of Student
Today's Date

MonthDayYear
Date
Agreement with intent to support:
Signature of Parent/Guardian
Today's date

MonthDayYear
Date
Photo/Media Release
I understand that I might be photographed and/or videoed while at Friends Youth Camp at Camp Muskingum in Carrollton, Ohio. I understand that photographs/videos may be taken by staff and consent to the use, without compensation, of these photographs/videos for communication purposes, such as communication with the churches, Friends Youth Camp website, Social media sites, and or other communications.
I understand.
Should be Empty:

Friends Youth Camp Student Health Form

Church Information

Student Information

Student Medical Information

Food Allergies

Seasonal/Other Allergies

Medication

Medication Allergies

Emergency Contacts

Consent to Treat/Medical Release

Friends Youth Camp Code of Conduct

Photo/Media Release