Camper health history form-2.2014-final

Camper Health To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your
completed CAMPER HEALTH HISTORY FORM (Form 1) to your child’s health-care provider for review.
History Form 2
Dates will attend camp: From ______________________________ to ____________________________ Camper Name _________________________________________________________________________ Mail this form to the address below at least three weeks prior to your Birth Date _______/_______/__________ Age on arrival at camp _________years /________months Camper home address: _________________________________________________________________ Skyland Camp for Girls
P.O. Box 128
_____________________________________________________________________________________ Clyde, NC 28721
Fax: 888-298-5711
Custodial parent(s)/guardian(s) phone: (________) _________________ (________) ________________ ____________________________________________________________ Questions?
Parents/Guardians: STOP here. The rest of this form is completed by medical
Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (Form 1) and complete all
remaining sections of this form (Form 2). Attach additional information if needed.
used on and as needed basis to manage illness and injury. Medical personnel: Cross out
No (If “no,” date of last physical ______/________/___________ those items the camper should
(Requirements specify a physical exam within 12 months prior to arriving at camp) NOT be given:

Ibuprofen (Advil, Motrin) Phenylephrine (Sudafed PE) Allergies:
To foods (list):
To medications: (list):
To the environment (insect stings, hay fever, etc.– list):
Other allergies: (list):
Describe previous reactions:
Laxatives for constipation (Ex-Lax) Hydrocortisone 1% cream Topical antibiotic cream Calamine lotion Aloe Diet/Nutrition:
Has a medically prescribed meal plan or dietary restrictions (describe below/on separate sheet)
Current Treatment(s): The camper is undergoing treatment at this time for the following conditions: (describe below)
Will take the following prescribed medication(s) while at camp: (describe name, dose, frequency)
Other treatment/therapies to be continued at camp (describe below/on separate sheet)
Do you feel that the camper will require limitations or restrictions to camp activity while at camp? (If you answered YES, what do you recommend? (Describe below/on separate sheet)
“I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’s parent(s)/
guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above.)”
Name of licensed provider: ________________________________________ Signature: ___________________________________Title: _____________ Office Address________________________________________________________________________________________________________________ __ Skyland Camp for Girls - Rev. 12/2013 Page 1/1


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