MEDICAL PERMISSION FORM*
CONCORDIA LANGUAGE VILLAGES, BIMIDJI, MN
September 27 – October 2, 2015
This form must be completed and returned to the
school office no later than August 15, 2015.
About Concordia Language Villages
Location: On Turtle River Lake near Bimidji in the
North Woods of northwest Minnesota.
Environment: An area of lakes, wetlands and mixed
forest near the headwaters of the Mississippi River
Weather: Temperatures range from highs in the 60s
to lows in the 30s. Rain occurs. Snow is possible.
Accommodations: Campers will stay in modern
heated cabins, each with its own bathroom. Spanish
speaking counselors stay in each cabin. Ancona
chaperones stay on site in separate cabins.
Medical Staff: A nurse is available on call on the
camp property, and counselors are trained in basic
emergency protocols. Definitive emergency care is
30 minutes away in Bimidji .
Activities: Campers will spend much of their days
and some of their evenings out-of-doors. Activities
may include but will not be limited to:
Outdoor games and classes
Hikes on trails in the woods
To Parent(s)/Guardian(s): Complete this section and give this form
to your child’s healthcare provider for review.
Camper Name_______________________________________
Birth Date _________________
Age at Camp____________
Parent(s)/Guardian(s) Phone:__________________________
Email: _____________________________________________
Remainder of form to be completed by medical personnel.
To Medical Personnel: Please complete all sections of this form.
Attach additional information as necessary.
Physical exam done today:  Yes  No If “no,” date of last physical:
_____/______/_________
Weight: _____lbs. Height: ____ft ____in Blood Pressure ____/____
Allergies:  No Known Allergies
 To Foods (list):
 To medications (list):
 To the environment (stings, hay fever, etc. list):
 Other allergies (list):
Describe previous reactions:
Campers with allergies must have an Allergy Action Plan on file
with The Ancona School.
Diet/Nutrition:  Eats a regular diet.  Has a medically prescribed meal plan or dietary restrictions (describe below):
The camper is undergoing treatment at this time for the following conditions (describe below): None
Campers with diabetes, seizure disorder and/or asthma must have the appropriate Action Plan on file with The Ancona School.
Medication:  No daily medications  Will take the following prescribed medication(s) while at camp: (name, dose, frequency) – describe below
Campers bringing medication to camp must have the appropriate medication form on file with The Ancona School.
Do you feel that the camper will require limitations or restrictions to activity while at camp?  No  Yes
If you answered yes, what do you recommend? (describe below – attach additional information if needed)
I 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, outdoor camp program (except as noted above).
Name of Licensed Provider (print) __________________________Signature: ______________________________Title _____________________
Address: ______________________________________________Telephone: (____)_________________________ Date:___________________
*based on form recommended by the American Camping Association