Health Form | redwood-1

Camper First Name

Camper Last Name

Birthday

Year

Month

Day

Medicare Card #

Expiry

Parent/Guardian Phone Number

Emergency Contact

Other

Severity of Allergies

Mild

Moderate

Severe

Immunizations to date

Yes

No

Epipen needed?

Yes

No

Has your child required behavioral counselling?

Yes

No

If yes, please share any information you feel comfortable with.

Dietary or activity restrictions for camp:

Medication to be given at camp (must be in original bottle):

Other Medical, Physical , Emotional or Behavioral Concerns and/or Recent Operations, Illness or Injuries

To the best of my knowledge, my child is healthy and has not been exposed to infectious diseases in the past 4 weeks. I will notify the camp in writing of any health status changes or exposure to infectious diseases. I have disclosed all pertinent medical information, including prescription medications. In case of emergency and if we are not available, I give permission to the camp's physician to hospitalize, treat, and order injections, anesthesia, or surgery for my child.

Summer Fun since 1974

Important Health Info!