Microsoft word - camp edow 2013 health form.doc

Due July 1, 2013 via mail – All information required •   ri
•   is al
Camper Name__________________________________________ Birthdate (Month, Day, Year)__________________
Parent/Guardian with legal custody to be contacted in case of illness or injury:

Name___________________________________ Relationship to camper______________________________________
Preferred Phone: ( )___________________________ E-mail: ____________________________
Second Parent/Guardian or other emergency contact:

Name:____________________________________ Relationship to Camper ____________________________________
Preferred Phones: ( )_______________________ E-mail: ____________________________________________

Camper’s Physician:__________________________________ Phone:____________________________________
Additional contact person in the event parent(s)/Guardian cannot be reached:

Name: ____________________________________ Relationship to Camper: ___________________________________
Preferred Phones: ( )____________________________ ( )________________________________
ALLERGIES:
□ No known allergies □ Food □ Medicine □ The environment (insect stings, hay fever, etc.) □ Other Please describe below what the camper is allergic to and the reaction seen.
Preference if needed: □Tylenol □Motrin □None
Activity RESTRICTIONS: (choose one)
I believe _______________________(camper name) can participate in swimming, canoeing, high or low ropes corse, archery, nature hikes, arts and crafts, drama, music, field day type games and Christian Education and Worship. □ with the following restrictions or accommodations (Please describe) Parent/Guardian Signature_________________________________________ Date_______________ Media Release — In the course of Camp EDOW pictures and video may be taken by diocesan staff or staff members. The
Episcopal Diocese of Washington has the right and permission to publish, copyright, and use pictures of those attending
diocesan events.
Note: It is the steadfast policy of the EDOW not to print the individual names of minors. If you are unwilling for your son/
daughter’s photo or voice to be used for promotion of diocesan events, please let the Camp EDOW Director know prior to the
event.
Parent/Guardian Signature_________________________________________ Date_______________
MEDICATIONS
List all of your camper’s medication, prescriptions and non-pr escriptions and reason: ____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Additional information about the camper’s health and development: _________________________________________
____________________________________________________________________________________________________ □ I understand that all medications are to be turned over to the camp nurse upon arrival and no child will
be allowed to self-administer with the exception of inhalers for asthma.

Please check approved Over the Counter Medications:
□acetaminophen (Tylenol) □ibuprofen (Advil/Motrin) □Pepto-bismol (bismuth subsalicylate)
N □ diphenhydramin (Benadryl) □hydrocortisone cream □topical sunscreen (spray and face lotion)
□Bug repellant spray □Neosporin (or generic) □ calamine lotion □ NONE
ALLERGIES:
□ No known allergies □ Food □ Medicine □ The environment (insect stings, hay fever, etc.) □ Other Please describe below what the camper is allergic to and the reaction seen:
Diet and Nutrition Restrictions or Accommodations ne eded:
Preference if needed: □Tylenol □Motrin □None
MEDICAL INSURANCE INFORMATION:
_______________________________________ is covered by medical/hospital insurance □ Yes □ No (Camper’s Name) Include a copy of the insurance card that cover’s this child; copy both sides of card so information is readable.
Insurance Company____________________________________ Policy Number______________________________ Subscriber_________________________________ Insurance Company Phone Number ( )___________________ PARENT/GUARDIAN AUTHORIZATION FOR HEALTH CARE:
This health history is correct and the person described has permission to participate in all 2013 Camp EDOW activities except as noted by me and/or an examining physician. I give permission, to the provider, selected by Camp EDOW to order x-rays, routine tests, and treatment related to the health of my child in emergency/urgent situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with the Camp EDOW staff. Signature of Custodial Parent/Guardian______________________________________________________________ Relationship to Camper__________________________________ Date_________________________________

Source: http://www.edow.org/ministries/diocesan/youth-ministry/Camp_EDOW_2013_Health_Form.pdf