Clone of Friends Youth Camp Health Forms

Friends Youth Camp Adult Health Form
Church Information

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

First NameLast Name
Adult Address

Street Address

Street Address Line 2

CityState / Province

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

Please complete all sections accurately.
Adult Birthday

MonthDayYear
Date
Are you covered by 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.
Do you 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
Do you 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 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 Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Adult
Consent to Treat/Medical Release
I hereby give permission for emergency treatment 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 the emergency contact 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.
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 Adult Health Form

Church Information

Adult Information

Adult Medical Information

Food Allergies

Seasonal/Other Allergies

Medication Allergies

Emergency Contact

Consent to Treat/Medical Release

Photo/Media Release