Camp tamarack

Camp Tamarack
CAMPER ANNUAL HEALTH HISTORY FORM
ALL CAMPERS MUST FILE THIS FORM EACH YEAR
An up-to-date Health History for all campers is required by State Law. This form must be completed and signed by a parent/guardian and presented to the Camp Health Officer upon arrival at camp.

Name of Camper ________________________________________________________ Sex M - F
Circle one

Address _______________________________________________E-mail______________________________

City __________________________________________ State __________ Zip Code ___________________

Res. Phone: _________/__________________________ Age __________ Birthday ________/_______/______
Month Day Year

Parent/Guardian Name ______________________________________________________________________

Business/Work Address _____________________________________________________________________

City __________________________ St ______ Zip ___________ Daytime Phone _______/_______________

If not available in an emergency, notify:_________________________________________________________

______________________________________________ Phone __________/ ___________________________

Name of Family Physician _______________________________________Phone __________/_____________

Medical Insurance Carrier __________________________________ Phone number_____________________

Policy Number _________________________________ Group Number_______________________________
CAMPERS HEALTH HISTORY
LIST MEDICATIONS – NAME OF MEDICATION, DOSE, AND FREQUENCY
_____________________________________________________________________________________________________
Medication Name
Frequency
_____________________________________________________________________________________________________
Medication Name
Frequency
_____________________________________________________________________________________________________
Medication Name
Frequency
_____________________________________________________________________________________________________
Medication Name
Frequency
ALLERGIES: ______________________________________________________________________________
IMMUNIZATION RECORD

VACCINES
Does camper have current vaccines? YES__________________
NO_____________________
YES__________________
DATE___________________

Important: Please notify the camp if this camper is exposed to any communicable disease during the three
weeks prior to camp.


The camper named has permission to participate in all prescribed camp activities except as noted below.
Exceptions (if any):_______________________________________________________________________________ I give permission for Camp Tamarack personnel to administer the following non-prescription medication to the camper as needed. Dosage will be based on age and weight. Please cross out any items, which are
Acetaminophen or Ibuprofen
Sore throat lozenges
Calamine lotion
Antibiotic ointment
Benadryl topical ointment
Anti-Itch ointment
Benadryl oral

I also give permission to the physician selected by the camp to order x-rays, routine tests and treatment for the health of
the above named camper. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for I understand that the camp does not carry health/accident insurance and I accept responsibility for the cost of any medical care provided whether or not it is covered by my family medical/hospital insurance. Person picking up camper is: ____________________________________________________________________ Person/persons who cannot pick up camper: ________________________________________________________ I also give my permission for the use of pictures including above camper to be used in promotional camping displays and brochures, without monetary reimbursement.
I certify that the information in this Health History is correct.

______________________________________________________________ Date ________________________
Parent/Guardian Signature
American Baptist Churches of Wisconsin

Source: http://www.camptamarack.org/documents/Health%20History%20Form%202011.pdf