HSLC Health Form

HERMANN SONS LIFE CAMP

HEALTH HISTORY FORM
Session - SPJST*
Camper Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Camper Age (on June 8, 2025)*
Camper Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent/guardian with legal custody to be contacted in case of illness or injury:
Name*
Relationship to Camper*
Preferred Phone Number - Cell/Mobile*
Format: (000) 000-0000.
Preferred Phone Number - Home*
Format: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Second Parent/Guardian or Other Emergency Contact:
Name*
Relationship to Camper*
Preferred Phone Number - Cell/Mobile*
Format: (000) 000-0000.
Preferred Phone Number - Home*
Format: (000) 000-0000.
Additional Emergency Contact:
Name*
Relationship to Camper*
Preferred Phone Number - Cell/Mobile*
Format: (000) 000-0000.
Preferred Phone Number - Home*
Format: (000) 000-0000.
Camper’s Primary Doctor’s Information:
Name*
Phone Number*
Format: (000) 000-0000.
Office Address*

Street Address

Street Address Line 2

CityState

Zip Code
Our Health Services Team is made up of Health Managers who are registered nurses, licensed vocational nurses, emergency medical technicians, or emergency responders. They have emergency first aid certification or documentation. Health Managers are at Camp all week, 24 hours a day, to care for the campers and staff. They dispense OTC and prescription medication, treat minor illness and injury, and refer patients to appropriate physicians when necessary. A parent or guardian will be notified if a doctor or hospital visit is required, if the camper spends a night in the clinic, or for any other medical reason deemed necessary by the Health Manager. In addition, a parent or guardian will be notified in the event of severe homesickness or for any other reason deemed necessary by the Camp Director. Any medical expenses incurred at Camp for an illness or injury pre-existing before Camp will be the responsibility of the parent or guardian. We cannot be responsible for information that is not disclosed to us. Any other medical bills will be discussed with the parent or guardian on an individual basis.
AUTHORIZATION FOR TREATMENT
I hereby give permission for Hermann Sons Life Camp and medical personnel selected by the Camp to provide routine health care; to administer medication, including any over-the-counter medications Camp medical personnel deem necessary; to order tests, X-rays, and treatment; to release any records necessary for reporting purposes; and to provide or arrange any necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician and health care facility selected by the Camp to secure and administer treatment, including hospitalization, for the person named in this document. I also attest that all information included in this form is correct and accurately reflects the health status of the camper to whom it pertains, so far as I know, and the person described has permission to engage in all Camp activities unless otherwise noted. 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. *

Signature of Custodial Parent or Guardian
Date*

MonthDayYear
Date
Relationship to Camper*

Rows	Medication	Dosage	When Dispensed
Medication #1
Medication #2
Medication #3

HERMANN SONS LIFE CAMP

AUTHORIZATION FOR TREATMENT

HEALTH HISTORY

Medical Conditions

Diseases

Allergies

Immunization History

FOR YOUR CAMPER’S SAFETY