Camper Health Form

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This field is for validation purposes and should be left unchanged.
All of the following information must be completed in order for your camper to be admitted to his or her camp event.
Name
First Last
Address
Street Address City State / Province / Region ZIP / Postal Code Country
Name of the Camp Event Camper is Attending*
Parent/Guardian Name*
First Last
Parent/Guardian Home Phone
Parent/Guardian Cell Phone
Parent/Guardian Work Phone

Emergency Contact Name*
First Last
Emergency Contact Phone*
Camper Insurance Carrier
Insurance Policy #
Insurance Group #
Doctor's Name*
First Last
Doctor's Phone*
Camper's Age (at time of camp event)
Camper's Weight
Date of Camper's Last Tetanus Shot
Did Camper Receive Hepatitis B Series?*
- Yes
- No
Does Camper Carry an Epi Pen?*
- Yes
- No
List Allergies, Medical Conditions, Special Needs
List medications camper is presently taking
Parent Authorization: I certify that this camper is in good health and may participate in ordinary camp activities. I give permission to the camp to provide routine health care, administer prescribed medications, seek emergency medical treatment including ordering x-rays or routine tests. I hereby give permission for Joy El to administer over-the-counter medications in accordance with Joy El’s Health Service Policy by the health care staff. Dosages will be administered according to the directions on the bottle unless a physician directs otherwise. I agree to the release of any records necessary for treatment, referral, billing, or insurance. I am aware that my child may be transported off of camp property for electives or all-camp trips. By submitting this form to Joy El, you are in agreement with the parent authorization.

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