Camper Form

Camper General Information
Camper Name*

First NameLast Name
Camper Birth Date*

MonthDayYear
Date
Camper Age at start of camp
Camper Sex*

MaleFemale
Which camp is your child attending?*

BrookwoodsDeer RunMoose River OutpostBoth NH and Maine camps
What is your camper's start date?*

June 28, 2026July 5, 2026July 12, 2026July 26, 2026August 9, 2026August 16, 2026
Which camp is your child going to first?

Brookwoods or Deer RunMoose River Outpost
Camper Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contacts
Please note: At least one emergency contact must be located within the United States. Ensure that the contact information provided reflects this requirement.
Primary Contact (must be located within the United States): In case of emergency, please contact the following person*

First NameLast Name
Primary Contact relationship to camper*
Primary Contact Home Phone Number

Area CodePhone Number
Primary Contact Cell Phone Number*

Area CodePhone Number
Primary Contact Work Number

Area CodePhone Number
Secondary Contact: In case of emergency, please contact the following person*

First NameLast Name
Secondary Contact relationship to camper
Secondary Contact Home Phone Number

Area CodePhone Number
Secondary Contact Cell Phone Number*

Area CodePhone Number
Secondary Contact Work Number

Area CodePhone Number
Do you have Health Insurance coverage for the camper?*

YesNo
Front of insurance card

Browse Files

Cancelof
Back of insurance card

Browse Files

Cancelof
General Health History

Has the camper ever:
Date of last physical (or date of scheduled physical)*

MonthDayYear
Date
Had surgery (tonsils, appendix, etc.)?*

YesNo
Explain: Surgery history
Been hospitalized?*

YesNo
Explain: Hospitalization
Recent illness (mono, etc.)*

YesNo
Explain: Recent illness
Recent injuries?*

YesNo
Explain: Recent injuries
Neurological issues? (Headaches, seizure, fainting, concussion, problems sleeping, etc.)*

YesNo
Explain: Neurological issues
Issues with ears, eyes, nose, throat? (glasses, hearing aids, swallowing problems, etc.)*

YesNo
Please explain yes answer
Cardiac issues? (abnormal heart rhythm, palpitations, fainting, etc.)*

YesNo
Explain: Respiratory issues
Gastrointestinal issues? (Food intolerance, diarrhea, constipation, incontinence)*

YesNo
Explain: Gastrointestinal issues
Urinary/reproductive issues (Bed wetting, painful periods, missed periods, etc)?*

YesNo
Explain: Urinary issues
Has menstruation started?

YesNo
Musculoskeletal issues? (Joint pain, fracture, break, limited movement, etc.)*

YesNo
Explain: Musculoskeletal issues
Skin issues? (eczema, hives, rashes, etc.)*

YesNo
Explain: Skin issues
Endocrine issues? (Thyroid, diabetes, etc.)*

YesNo
Explain: Endocrine issues
Traveled outside the country in the past 9 months?*

YesNo
Explain: Mental/emotional treatment
Mental, Emotional and Social Health
Ever been treated for attention deficit disorder (ADD) or attention deficit / hyperactivity disorder?*

YesNo
Please explain yes answer
Ever been treated for emotional or behavioral difficulties or an eating disorder?*

YesNo
Please explain yes answer
During the past 12 months, seen a professional to address mental/emotional health concerns?*

YesNo
Please explain yes answer
Had a significant life event that continues to effect the camper's life? (History of abuse, death of a loved one, family change, adoption, foster care, survived a disaster, etc.)*

YesNo
Please explain yes answer
Allergies and Asthma
Respiratory issues? (asthma, cough, wheezing)*

YesNo
Please explain yes answer
Does the camper need to carry an inhaler with them?

YesNo
IMPORTANT - If your child needs to carry an inhaler with them, the Epi-pen form must be filled out by their doctor! Inhaler/ Epi-pen (This form will open in a new window and will not reset your progress)
Does the camper have any allergies to food, medication, stings, the environment or anything else?*

YesNo
Allergy Desensitization / Oral Immunotherapy (OIT)
If your camper is currently undergoing food allergy desensitization or oral immunotherapy (OIT), we require written clearance from the treating medical provider confirming that the program may safely continue in the camp setting. Please email Corey for a copy of that document.
Allergy List
Does the camper have an epi-pen?

YesNo
IMPORTANT - If your child needs to carry an Epi-pen with them, the Epi-pen form must be filled out by their doctor! Inhaler/ Epi-pen (This form will open in a new window and will not reset your progress)
Does the camper have any special food restrictions?*

YesNo
Please list any special food restrictions
Medication information
Does the camper take any prescription medications or vitamins they will take during their session of camp? (Over the counter medication info will be asked later in this form)*

YesNo
IMPORTANT: All prescription medications, supplements, and vitamins must have a current provider order on file or they will not be accepted at camp.

All medications must be in the original packaging (daily sorters/pill organizers are not permitted). Please only send enough medication for the week of camp. The original prescription package with the camper’s name and pharmacy label is sufficient to meet the prescription labeling requirement.
Medications given at BREAKFAST
Medications given at LUNCH
Medications given at DINNER
Medications given at BED TIME
Medications given AS NEEDED OR OTHER TIME
Over the Counter Medications

A&D ointment Acetaminophen Aloe Vera gel Anbesol Caladryl lotion Cetirizine Cortisone topicals Dayquil Dextromethorphan Dextromethorphan ER Diclofenac topical Diphenhydramine Dramamine Emetrol Epsom Salts Eye drops with lubricating or soothing properties Eyelid hygiene wash solution or wipes Famotidine Guaifenesin Hydrocortisone 1-2% Ibuprofen Imodium AD Insect repellant Lidocaine topical Loratadine Lotrimin Midol Milk of Magnesia Miralax Probiotic Pseudoephedrine Sunscreen Swimmer’s ear prevention drops (hydrogen peroxide/alcohol) Throat Lozenges Tums Zofran (ondansetron)
Maine State law requires all medication administered to campers, including over the counter medication and vitamins to have a prescription from a Medical Provider.
Will you be bringing any over-the-counter medications (not including vitamins) to camp not listed above?

YesNo
Over the counter medications
Permission to Administer Medication:

I give permission for Christian Camps and Conferences, Inc. medical staff to administer the following over-the-counter medications to my child, as needed, according to proper dosage guidelines. I understand that these medications will only be given for their intended uses and that all efforts will be made to contact me if there is any concern.
Immunizations
Date of Last Tetanus

MonthDayYear
Date
Has your child been fully immunized?

Yes (please include a copy of the immunization record with the Medical Provider's form.No
Signature of Custodial Parent/Guardian

If your child has NOT been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized.
Date

MonthDayYear
Date
Relationship to Camper
Health Care Providers:
Name of camper's primary doctor:
Doctor's phone number

Area CodePhone Number
Name of camper's dentist:
Dentist's phone number

Area CodePhone Number
Name of camper's orthodontist:
Orthodontist's phone number

Area CodePhone Number
What have we forgotten to ask?
Please provide in the space below any additional information about the camper's health that you think is important or that may affect the camper's ability to fully participate in the camp program.
Medical Information Signature
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician.

I authorize the camp’s health staff to assess, treat, and manage my child’s medical needs during their time at camp, including the administration of prescribed medications and approved over-the-counter medications in accordance with provider orders and camp policies.

I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and emergency situations. If I cannot be reached in an emergency, I give permission for appropriate medical care, including hospitalization, securing proper treatment, and ordering injections, anesthesia, or surgery for this child.

In emergency situations, I understand and agree that the camp’s health staff may administer life-saving treatments and medications as deemed necessary to protect the health and safety of my child until additional medical care can be obtained.

I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child, and these providers may communicate with the program’s staff regarding my child’s health status.
Parent/Guardian Name*

First NameLast Name
Medical Information: Parent/Guardian Signature*
Date of Signature*

MonthDayYear
Date
Parent/Guardian Email Address:
example@example.com

Camper General Information

Emergency Contacts

General Health History

Mental, Emotional and Social Health

Allergies and Asthma

Medication information

Over the Counter Medications

Immunizations

Health Care Providers:

What have we forgotten to ask?

Medical Information Signature

Transportation Information