CAMPER ANNUAL HEALTH HISTORY FORM
ALL CAMPERS MUST FILE THIS FORM EACH YEAR
An up-to-date Health History for all campers is required by State Law.
This form must be completed and signed by a parent/guardian and presented
to the Camp Health Officer upon arrival at camp.
Name of Camper ________________________________________________________ Sex M - F
City __________________________________________ State __________ Zip Code ___________________
Res. Phone: _________/__________________________ Age __________ Birthday ________/_______/______
Month Day Year
Parent/Guardian Name ______________________________________________________________________
Business/Work Address _____________________________________________________________________
City __________________________ St ______ Zip ___________ Daytime Phone _______/_______________
If not available in an emergency, notify:_________________________________________________________
______________________________________________ Phone __________/ ___________________________
Name of Family Physician _______________________________________Phone __________/_____________
Medical Insurance Carrier __________________________________ Phone number_____________________
Policy Number _________________________________ Group Number_______________________________
CAMPERS HEALTH HISTORY
LIST MEDICATIONS – NAME OF MEDICATION, DOSE, AND FREQUENCY
Does camper have current vaccines? YES__________________
Important: Please notify the camp if this camper is exposed to any communicable disease during the three
weeks prior to camp.
The camper named has permission to participate in all prescribed camp activities except as noted below.
Exceptions (if any):_______________________________________________________________________________ I give permission for Camp Tamarack personnel to administer the following non-prescription medication
to the camper as needed. Dosage will be based on age and weight. Please cross out any items, which are
Acetaminophen or Ibuprofen
Sore throat lozenges
Benadryl topical ointment
I also give permission to the physician selected by the camp to order x-rays, routine tests and treatment for the health of
the above named camper. In the event I cannot be reached in an emergency, I hereby give my permission to the
physician selected to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for
I understand that the camp does not carry health/accident insurance and I accept responsibility for the cost of any
medical care provided whether or not it is covered by my family medical/hospital insurance.
Person picking up camper is: ____________________________________________________________________
Person/persons who cannot pick up camper: ________________________________________________________
I also give my permission for the use of pictures including above camper to be used in promotional camping displays
and brochures, without monetary reimbursement.
I certify that the information in this Health History is correct.
______________________________________________________________ Date ________________________
American Baptist Churches of Wisconsin
Pertussis, or whooping cough, is a highly contagious bacterial infection that causes an uncontrollable, violent cough lasting several weeks or even months. It is caused by a bacterium that is found in the mouth, nose and throat of an infected person. Pertussis may begin with cold-like symptoms or a dry cough that progress Pertussis can occur at any age. Children who are too young to be fully va
Date of Birth: It is very important to complete ALL sections. This form will help you prepare for the initial assessment as trying to remember past episodes and treatments during the actual interview can be difficult. In turn, it helps me understand your illness as the medical chart is not enough. If necessary, your Counsellor is available to help you complete the form. 1) Your exp