Camp Tamarack 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 Circle one Address _______________________________________________E-mail______________________________ 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 _____________________________________________________________________________________________________ Medication Name Frequency _____________________________________________________________________________________________________ Medication Name Frequency _____________________________________________________________________________________________________ Medication Name Frequency _____________________________________________________________________________________________________ Medication Name Frequency ALLERGIES: ______________________________________________________________________________ IMMUNIZATION RECORD VACCINES Does camper have current vaccines? YES__________________ NO_____________________ YES__________________ DATE___________________ 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 Calamine lotion Antibiotic ointment Benadryl topical ointment Anti-Itch ointment Benadryl oral 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 ________________________ Parent/Guardian Signature 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