Wilderness AdventuresText Box: Camper Health Record Form *MUST BE COMPLETED TO ATTEND , PLEASE PRINT CLEARLY Name _____________________________________________Sex M ____ F ____ Address ___________________________________City_______________________ State/Prov_______________ Zip/Postal Code _____________ Age__________Date of Birth: Month________ Day__________ Year___________ Parents_______________________________________________________________ Parents home phone________________________, Parents work phone ________________________ In an emergency contact ________________________________ Relationship__________________________, Home phone__________________________,Work phone_____________________ Does the camper have physical limitations? Yes____ No____ (If yes, please explain) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Rate the camper’s swimming ability: Excellent ____ Good ____ Fair ____ Poor ____ HEALTH HISTORY—Has the camper had any of the following: Chicken pox ___ Measles___ Mumps___ Appendectomy___ Frequent Colds ____ Does the camper have problems with any of the following:Heart___ Ears___ Skin___ Hernia___ Stomach: Indigestion___ Nausea/Vomiting___, Lungs-Hay Fever___ Asthma___ Diabetes___ Seizures___ Headaches___ ADD____ Allergies (Please list) Reaction Degree (severe, moderate, mild) 1._______________________________________________________________________________________________________ 2. ______________________________________________________________________________________________________ 3. __________________________________________________________________ Last Tetanus Immunization __________________ (please be sure this is up to date before camp. Up to date means within the past 10 years.) Has the camper ever been away from home longer than a week? Yes____ No____ Please provide us with any other health information about the camper that would be helpful: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ MEDICATIONS: All medications other than those needed on an immediate basis by the camper (i.e., bee sting kit) will be kept in the possession of the camp nurse. Please send medications in their original container (i.e., prescription bottle). Please list all medications currently used by the camper. Medication Dose Time(s) of day _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ EMERGENCY CARE AUTHORIZATION: In the case of an emergency, I understand that every effort will be made to contact parents or guardians of campers. In the event that I cannot be reached or in the urgency of circumstances makes it necessary, I hereby give permission to the physician selected by the camp director or his designee to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery to my child named above. Signature __________________________________________Date__________________ Relationship to Camper_____________________________________________________ Insurance Company___________________________________ Policy #____________________________________________ Back Forward