Camp Hope Health History and Examination Form for New and Returning Campers

Camp Hope Health History and Examination Form for New and Returning Campers

To be completed and signed by a parent/guardian
Name of camper

First NameLast Name
Camper date of birth

MonthDayYear
Date
Camper Address

Street Address

Street Address Line 2

CityState

Zip Code
Name of Physician

First NameLast Name
Physician Address

Street Address

Street Address Line 2

CityState

Zip Code
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Does the camper have any medication, food, environmental or other allergies?
Allergies
Medication Allergies
Food Allergies
Other Allergies
List any medications your camper will take during camp hours (9am-2pm). If none, please put N/A
List any dietary restrictions (if none please put n/a)
List any activity restrictions (if none please put n/a)

Health History

Rows	Current	History	Explanation of Current Status
A) Asthma
B) Diabetes
C) Frequent Colds
D) Pneumonia
E) Lung/Breathing Problems
F) Seasonal Allergies/Other
G) Ear Infections
H) Frequent Headaches
I) Serious Skin Problems
J) Gum Problems
K) Dental Problems
L) Hypertension
M) Heart/Circulatory Problems
N) Stomach/Digestive Problems
O) Kidney/Urinary Problems
P) Pica (eats inedible objects)
Q) Hepatitis B Carrier
R) Seizure Disorder***
None of the above

Seizure Information Form - for New and Returning Campers

To be completed and signed by a parent/guardian
Name of Camper

First NameLast Name
Does your camper have a seizure disorder?
BY SIGNING BELOW I CONFIRM MY CAMPER DOES NOT HAVE A SEIZURE DISORDER

Clear

I permit the Arc of Essex County staff to apply sunscreen to my camper:
This authorization covers the period in which the Camp Hope staff is providing care to the camper.

Clear
Please DO NOT administer any sunscreen to camper

Clear
Sunscreen Type(s)

Seizure Information Form - for New and Returning Campers