Sample Camp Health Assessment Form printable pdf download

Session Attending: _____________

Health Form

Camper’s Name_____________________________ Birth Date_________ Age At Camp____ M F

Home Address ________________________ City ____________ State____ Zip______

Parent/Guardian _______________________________________ Phone_____________

Home Address ________________________ City____________ State_____ Zip ______

(If different from above)

Primary Contact ___________________________________ Phone_________________

Business Address______________________ City_________ Phone________________

Second parent or guardian or emergency contact _________________________________

Address__________________________________________ Phone________________

Insurance Company:____________________________ Policy Number_______________

If not available in an emergency, notify:

Name ___________________________________________________________________

Relationship _______________________________________ Phone _________________

Health History:

Allergies ____________________________________ Tetanus Date: _______

Food Allergies __________________________________________

Restrictions ____________________________________________

Additional Information we should know (past illnesses, behavior, concerns)

______________________________________________________________________________

Parent/Guardian Authorization: This health history is correct and complete as far as I know. The

person herein described has permission to engage in all camp activities except at noted.

I here by give permission to the camp to provide routing health care. In the event I cannot be reached

in an emergency, I hereby give permission to director to secure and administer treatment, including

hospitalization, for the person named above.

I also give permission that any photos taken of the person mentioned above might be used for camp

advertising.

Signature of parent /guardian ________________________________________

Sample Camp Health Assessment Form