Camp Weloki – Camper Health History & Parent/Guardian Authorization for Medical Treatment
The information on this form is gathered to assist us in identifying appropriate care. Any changes to this form should be provided to
camp health personnel in writing upon the participant’s arrival at camp.
TODAY’S DATE:_______________
CAMPER INFORMATION:
Name _____________________________________ Birth Date __________________ Age at camp _____  Male  Female
Home address________________________________________________________________________________________________
Custodial parent/guardian _____________________________________________________Home Phone ______________________
Other phone numbers, work _________________________________ cell or other _________________________________________
Second parent/guardian or emergency contact ______________________________________________________________________
Address ____________________________________________________________________ Phone __________________________
Other phone numbers work _________________________________ cell or other _________________________________________
If not available in an emergency, contact __________________________________________________________________________
Relationship ________________________ Phone numbers ___________________________________________________________
Insurance Information: Is the camper covered by family medical/hospital insurance?
 Yes  No
If so, indicate carrier or plan name ______________________________________________________ Group # __________________
Name of insured _______________________ SS# _______________________ Relationship to participant _____________________
IMPORTANT - Please attach copy of your insurance card (both sides) to this form
HEALTH HISTORY: The following must be filled out by the parent/guardian.
Allergies: List all known.
Describe reaction and management of the reaction.
Medication allergies (list)
______________________
_______________________________________________________________________________
______________________
_______________________________________________________________________________
______________________
_______________________________________________________________________________
Food allergies (list)
______________________
_______________________________________________________________________________
______________________
_______________________________________________________________________________
______________________
_______________________________________________________________________________
Other allergies (list) – include insect stings, hay fever, asthma animal dander, etc.
______________________
_______________________________________________________________________________
______________________
_______________________________________________________________________________
MEDICATIONS: Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough
medication to last entire time at camp. Keep medications in the original packaging/bottle that identifies the prescribing physician (if a
prescription drug).
 This person takes NO medications on a routine basis.
OR
 This person takes medication as follows:
Med #1 _______________________________ Dosage _________ Specific time/s taken each day _____________________________
Condition Treated__________________________________________________________________________________________
Med #2 _______________________________ Dosage _________ Specific time/s taken each day _____________________________
Condition Treated ____________________________________________________________________________________________
Med #3 _______________________________ Dosage _________ Specific time/s taken each day _____________________________
Condition Treated ____________________________________________________________________________________________
Attach additional pages for more medications as needed.
Identify any medications taken during the school year that participant does/may not take during the summer:
____________________________________________________________________________________________________________
RESTRICTIONS- The following restrictions apply to this individual.
Does not eat:  Red meat  Pork  Dairy products  Poultry
 Seafood
 Eggs
 Other(describe)________________
Explain any restrictions to activity (e.g. what cannot be done, what limitations or adaptations are necessary)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PLEASE TURN OVER FOR PG.2
GENERAL QUESTIONS (Explain “yes” answers below)
Has/does the participant:
Yes No
1. Had any recent injury, illness or infectious disease? 

2. Have a chronic or recurring illness/condition?


3. Ever been hospitalized?


4. Ever had surgery?


5. Have frequent headaches?


6. Ever had a head injury?


7. Ever been knocked unconscious?


8. Wear glasses, contacts or protective eyewear?


9. Ever had frequent ear infections?


10. Ever passed out during or after exercise?


11. Ever been dizzy during or after exercise?


12. Ever had seizures?


13. Ever had chest pain during or after exercise?


14. Ever had high blood pressure?


15. Ever been diagnosed with a heart murmur?


16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
Ever had back problems?
Ever had problems with joints/ (knees, ankles)
Have orthodontic appliance brought to camp?
Have any skin problems?
Have diabetes?
Have asthma?
Had mononucleosis in the past 12 months?
Had problems with diarrhea/constipation?
Have problems with sleepwalking?
If female, have an abnormal menstrual history?
Have history of bedwetting?
Ever had an eating disorder?
Ever had emotional difficulties for which you
sought professional help?
Yes












No














Please explain any “yes” answers, noting the number of the question:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Check any of the following boxes if child has had:
 Measles  Chicken pox  German measles
 Mumps
 Hepatitis A
 Hepatitis B
 Hepatitis C
IMPORTANT: Please attach copy of current immunization history from doctor’s office.
Name of physician _________________________________________________________ Phone _____________________________
Name of family dentist/orthodontist ___________________________________________ Phone______________________________
Important – These boxes must be complete for attendance
Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has
permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care,
administer prescribed medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the
release of any records necessary for insurance/medical purposes. I give permission to the camp to arrange necessary related
transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by
the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be
photocopied for any trips out of camp.
Signature of parent/guardian ____________________________________________________________________________________
Printed name __________________________________________________________________ Date __________________________
I also understand and agree to abide by any restrictions placed on my participation in camp activities.
Signature of camper ____________________________________________________________ Date _______________________
Review Record - For camp use only:
Reviewed by: Monitor____________________ Nurse ____________________
Current health needs identified:__________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Observational notes ___________________________________________________________________________________________