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Health Form
Complete this form to provide the child’s health, insurance, medication, and authorization information for a program or camp.
Child Information
Child’s Name - Last
*
Child’s Name - First
*
Sex
*
Please Select
F
M
Other
Gender Expression
*
Please Select
Female
Male
Transgender
Non-binary
Gender Queer
Other
Child's gender
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Parent / Guardian Contact Information
Guardian 1 Name
*
Guardian 1 Email
*
Guardian 1 Home Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian 1 Work Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian 1 Cell Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian 2 Name
*
Guardian 2 Email
*
Guardian 2 Home Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian 2 Work Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian 2 Cell Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Information
Health Insurance Company
Policy Number (Primary Insurance)
Policy Holder Name (Primary Insurance)
Group Number (Primary Insurance)
Relationship to Insured (Primary Insurance)
Second Health Insurance Company
Policy Number (Secondary Insurance)
Policy Holder Name (Secondary Insurance)
Group Number (Secondary Insurance)
Relationship to Insured (Secondary Insurance)
Medical Providers and Healthcare History
Preferred Hospital
Nephrologist
PCP (Primary Care Provider) Name
PCP Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
PCP Address
Clinic Visits in past 12 months
ER Visits in past 12 months
Hospitalizations in past 12 months
Missed School Days in past 12 months
Significant past medical history / other medical conditions
Development appropriate for age?
Please Select
Yes
No
Development explanation (if necessary)
Communication / psychosocial / behavioral problems affecting participation
Food restrictions, special diet, and/or food allergies
Mobility devices (wheelchair, scooter, braces, crutches, etc.)
Devices currently in place
Central line
G-tube
Ostomy
VP shunt
Pacemaker
PD Catheder
Other
Other device (specify)
Specific instructions for care of devices
Allergies
EPI Pen?
Please Select
Yes
No
N/A
Fluid hydration restriction/goal
Typical day description / reminders / acceptable beverages
Other concerns or information about camper
Medication Authorization
Medication 1
*
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Medication 11
Medication 12
Medication 13
Medication 14
Medication 15
Authorization Signature
Parent / Guardian Printed Full Name
*
First Name
Last Name
Parent / Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: