Camper Health History Form - 2017

Note: before you begin the form, have the following information handy (this is a long form and you cannot save it mid-way through).

  • Parent/guardian and emergency contact information
  • Camper's health insurance information (if applicable)
  • Camper's immunization records, including the date camper received the Tetanus booster.
  • Camper's medication information

Camper Name *
Camper Name
Gender *
Birth date *
Birth date
Which session is he/she attending? *
Camper home address *
Camper home address
Guardian Information / Emergency Contacts
Parent or guardian to be contacted in case of illness or injury *
Parent or guardian to be contacted in case of illness or injury
Preferred phone number *
Preferred phone number
Additional phone number
Additional phone number
Home address (if different from camper's)
Home address (if different from camper's)
Second parent/guardian or other emergency contact *
Second parent/guardian or other emergency contact
Preferred phone number *
Preferred phone number
Additional phone number
Additional phone number
Additional contact in the event parent/guardian cannot be reached *
Additional contact in the event parent/guardian cannot be reached
Preferred phone number *
Preferred phone number
Additional phone number
Additional phone number
Camper health information
Please describe any known allergies that the camper has. If the camper has no known allergies, leave this blank or write N/A.
Diet/Nutrition - select all that apply *
Note: there will be a vegetarian option available at each meal. If your child is gluten-free, dairy-free or has a significant food allergy, we ask that you please provide substitutes (e.g. soy milk, gluten-free bread).
Describe any additional diet/nutrition information about the camper that we should be aware of.
Restrictions *
Describe restrictions / adaptations below
Medical insurance information
This child is covered by medical insurance *
If you do not have insurance, that is OK. Camp Gallagher's insurance covers families that don't have health insurance.
(if you are insured)
(if you are insured)
(if you are insured)
Insurance company phone number
Insurance company phone number
(if you are insured)
Authorization for healthcare
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy a print version of this form. In addition, the camp has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.
Confirm your authorization *
Describe your relationship to the camper
Immunizations
Please check 'up to date' to confirm the camper is up to date on all of his/her immunizations.
Diptheria, tetanus, pertussis (DTaP) or (TdaP) *
Date of last Tetanus booster (dT) or (TdaP) *
Date of last Tetanus booster (dT) or (TdaP)
Mumps, measles, rubella *
Polio *
Haemophilus influenzae type B (HIB) *
Pneumococcal (PCV) *
Hepatitis B *
Hepatitis A *
Varicella (chicken pox) *
Pick one
Meningococcal meningitis (MCV4) *
Medications
Will the camper take medications while at camp? *
For all medications please write the following:
  • Name/type of mediation
  • Date he/she began taking it
  • Reason for taking it
  • Time of day he/she needs to take it
  • Amount of dose given
  • How it is given
  • Do NOT allow my child to take the following non-prescription medications
    The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness or injury.

    Select those that the camper should NOT be given, if any.
    General health history
    Select 'yes' or 'no' to the following questions, and then describe all 'yes' answers in the text field below.
    Has the camper ever been hospitalized? *
    Has the camper ever had surgery? *
    Does the camper have a chronic/recurring illness? *
    Has the camper had a recent infectious disease? *
    Has the camper had asthma/wheezing/shortness of breath? *
    Does the camper have diabetes? *
    Has the camper had seizures? *
    Has the camper had headaches? *
    Does the camper wear glasses, contacts or protective eyewear? *
    Has the camper had fainting or dizziness? *
    Has the camper passed out/had chest pain during exercise? *
    Has the camper had mononucleosis ("mono") during the past 12 months? *
    If female, does the camper have problems with periods/mestruation? *
    Does the camper have problems with falling asleep/sleepwalking? *
    Has the camper ever had back/join problems? *
    Does the camper have a history of bedwetting? *
    Does the camper have problems with diarrhea/constipation? *
    Does the camper have skin problems? *
    Has the camper traveled outside the country in the past 9 months? *
    Please explain "Yes" answers in the space below. For travel outside the country, please name countries visited and dates of travel.
    Mental, Emotional and Social Health
    Select 'yes' or 'no' for the following questions, and then describe all 'yes' answers in the text field below.
    Has the camper ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)? *
    Has the camper ever been treated for emotional or behavioral difficulties or an eating disorder? *
    During the past 12 months, has the camper seen a professional to address mental/emotional health concerns? *
    Has the camper had a significant life event that continues to affect the camper's life? *
    (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, etc.)
    Please explain "Yes" answers in the space below. We may contact you for additional information.
    Healthcare providers
    Any additional information
    Please provide in the space below any additional information about the camper's health that you think important or that may affect the camper's ability to fully participate in the camp program. Email us (info@campgallagher.org) with any additional health forms/documents you think we need to have.