Columbus Youth Camp
Health Assessment
(Confidential)
Name:
First Name
Last Name
Sex:
Age:
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Physician:
Phone:
Format: (000) 000-0000.
Do you have medical insurance? Y/N
Carrier:
Allergies (please check all that apply):
Hay Fever
Ivy Poisoning, etc.
Insect Stings
Asthma
Penicillin
Other Drugs
Other (please list)
Are you taking any medications while at camp? Y/N
If so, what?
Medical Conditions (include conditions that may affect your participation)
Medical Conditions
Heart Conditions
Epilepsy/Seizures
Diabetes
Vision/hearing impairment
Mental conditions
Hepatitis
Blackout/dizzy spells
Arthritis
Infections
Pregnancy
Other
Injuries (include conditions that may affect your participation)
Injuries
Strain/sprain
Dislocation(s)
Back injury
Head injury
Fracture/break
Hernia
Other
Are Immunizations Current?
Date of last tetanus shot?
Special Dietary considerations:
Emergency Contact
Name
First Name
Last Name
Home Phone #
Format: (000) 000-0000.
Mobile Phone #
Format: (000) 000-0000.
Work Phone #
Format: (000) 000-0000.
Acknowledgment of Risk and Safety
Your signature below verifies that you:
1) Have completed the Health Assessment form to the best of your knowledge;
2) Recognize that there are inherent risks in any outdoor pursuit, and agree to follow instructions and directions given by your leaders, act prudently, use good judgment, and assume a shared responsibility for your safety;
3) Understand that information may be collected and shared for the purposes of demonstrating outcomes or securing funding.
4) Agree that your participation is voluntary, and further agree to indemnify, release and hold harmless the Foundation For Youth, Columbus Youth Camp, its directors, officers and employees from any and all claims or damages for any accident, injury or illness arising out of the use of facilities, equipment and/or participation in Columbus Youth Camp activities;
5) Allow the Columbus Youth Camp Staff to provide routine health care, administer prescribed and parent provided OTC medications, and seek & provide emergency medical treatment where deemed necessary.
Participant Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
(If participant is under 18 years of age)
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