Camp subiaco june 17 - 24

Camp Subiaco Medical History Form
To be completed by parents or guardian

Camper's Name ___________________________________________________ ______________________________ Parent or Guardian ________________________________________________ Name__________________________________________________________ Contact Phone # _______________________________________ Family Health Insurance Carrier ________________________________________________________ Policy Number ___________________________ Group Number _____________________________ Name of Insured ________________________________________________ Authorization required from primary care physician prior to treatment Health History – Please circle
If answer (yes) above, please write a detailed description of the health history: ______________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ Please list all allergies: ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Operations or Serious Injuries (give dates): ______________________________________________________________ ________________________________________________________________________________________________ Broken Bones (What bone and when)? _______________________________________________________________ Any specific activities to be restricted? ________________________________________________________________ _______________________________________________________________________________________________
Please list all medications. All medication must be in the original pill bottles labeled with the child’s name, pharmacy,
medication name and dosage. Please send only the exact amount of medication that this child will need for the six days.
No medication will be returned. All over-the-counter medications must be turned in to camp counselors.
Name of Medication

IMPORTANT: Please notify the camp management if this camper has been exposed to any communicable disease
during the three weeks prior to camp attendance.
Suggestions from Parents ___________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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Parents Authorization
This health history is correct as far as I know and the person herein described has permission to engage in all prescribed camp activities, except as noted by the examining physician and me. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. Signature ________________________________________________________ Date ___________________________ Medication Release Form

The following medications will be available for your child should he need it. If your child CANNOT or should not take one
or more of these medications, please mark through it.
I _____________________________ (Parent or Guardian) request that you give ________________________ (Camper) his medication during camp. I understand that the camp physician, nurse or their designate will administer this medication. My child may also receive medications from the above list as needed under the guidance of the camp physician or nurse. I will not hold the camp staff responsible for undesired reactions to medications. Signature ______________________________________________________ Date: ___________________________

Source: http://www.campsubiaco.org/MedicalForm.pdf