Medical History and Release Form for Minors – Child Care Assistants

* required

Weekend You Will Be Attending:*

Child’s Name:*

Birthdate:*

Gender:*

Age:*

Parent or Guardian:*

Relationship:*

Cell Phone:*

Other Phone:

Second Parent or Guardian:

Second Parent Relationship:

Second Parent Cell Phone:

Second Parent Other Phone:

Emergency Contact Name:*

Emergency Contact Relationship:*

Emergency Contact Cell Phone:*

Emergency Contact Other Phone:

My Child’s Condition:
ADD/ADHDAsthmaDiabetesEpilepsyHeart conditionEye, ear, nose, throat issuesInjuryOther

Explanation/Other Concerns:



My Child’s Allergies:
Hay feverPoison Oak/IvyBeesOther insects/animalsPenicillinOther drugsPeanutsOther food

Explanation/Other Allergies:



My Child’s Limitations:
Activity restrictionsDietary restrictions

Explanation/Other Limitations:



List your child’s medication that will be taken while at camp. List condition above for which medication is needed. Be specific about dosage and time needed as a Health Care Coordinator will be administering your child’s medication:



May we give your child over-the-counter medications e.g. Tylenol, Advil, Benadryl, etc.?*:

Any other suggestions, documents or health-related information for camp personnel?:



Name of Physician:*

Phone:*

Health Insurance Carrier:*

Policy #:*

AUTHORIZATION
This health history is correct to the best of my knowledge. My child has permission to participate in activities that may include the swimming pool and challenge course, except as noted. I give permission to the medical personnel selected by the camp administration to order X-Rays, routine tests, and treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child if I cannot be reached in an emergency. I give permission to the health professional selected by the camp administration to secure and administer treatment for my child, including hospitalization.

Camp staff is CPR, First Aid and AED certified. I understand that I will be notified if my child breaks a bone, has extensive bleeding, a head injury, or any other medical need that necessitates staff seeking outside help or calling 911. Camper medication must be checked in with the Camp Director, or Health Care Supervisor in the original bottle upon arrival. CAMP WILL NOT ACCEPT MEDICATION THAT IS NOT IN ITS ORIGINAL BOTTLE.

I accept full responsibility for any injury my child might receive as a result of camp activities. I will provide my own health and accident insurance. I agree to pick up my child at any time from camp if asked to by camp administration.

I agree to the above authorization*: