Kingsteamcamp.org

CAMPER HEALTH REPORT/RELEASE

NOTE: State law requires that this Health Report be signed by a Physician or Nurse Practitioner.
Camper’s Name:
Birth Date
Medicaid Number
Insurance Company
Camper I.D./Policy No.
PARENT/GUARDIAN STATEMENT & RELEASE:

Medical Release:
This health history is correct so far as I know, and the above named camper has permission to engage in all
prescribed program activities except as noted. The undersigned do hereby authorize the directors of King’s Team
Camp or such substitute as they may designate as agent for the undersigned to consent to an x-ray examination,
anesthetic, medical, dental or surgical diagnosis or treatment and hospital care for the minor which is deemed
advisable by and to be rendered under the general or special supervision of any physician or surgeon, licensed under
the provision of the Medical Practice Act or any dentist licensed under the Dental Practice Act, whether such
diagnosis or treatment is rendered at the office of said physician or dentist, at a hospital, camp, or elsewhere. This
authorization will remain in effect while the minor is enroute to and from, or involved or participating in any camp
program, unless revoked in writing by the undersigned and delivered to the Director of King’s Team Camp.
Permission to administer over-the counter medications:
Medication
Other Instructions
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Please indicate any medication child is currently taking: (Please print clearly)
All medication sent to camp must be in original container with the pharmacy label on it and given
to the camp nurse at registration. Please be sure to pick up camper’s medication(s) from the camp
nurse when you pick up your camper
MEDICATION
MEDICAL DIAGNOSIS

If necessary, King’s Team Camp Director may also administer medications to Camper:
Yes

Signature of Foster Parent:

Signature of Legal Guardian:

Signature of Case Worker:
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PHYSICIAN'S EXAM AND STATEMENT:

Health History:

Date of last immunization for:

Please indicate ANY known allergies -- BE SPECIFIC!

Bee Sting
List any serious or medical problem within the last year or any physical condition the Camp Nurse should be aware of. Camp altitude is approximately 9,000 feet. 1.
I have examined this camper and found him/her to be in satisfactory physical condition, free from any
contagious disease and capable of active participation in a regular camp program except:


Signature of Physician or Nurse Practitioner:
Name of Physician/Nurse Practitioner (Please Print)
________________________________________________________________________
Address:

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Source: http://kingsteamcamp.org/doc/Camper_Health_Report.pdf