Camper Profile:

Physical Health: __Excellent __Good __Fair

__Poor

Temperament: __Timid __Quiet __Sensitive

__Average __Excitable __Aggressive __Other

Joins in group activities: __Easily __With

Difficulty

Known fears or weakness: ________________

Eating and Sleeping Habits: ______________

Any Activity Restrictions: ________________

____Can swim ____Cannot swim

Allergies:

_______________________________

_______________________________

_______________________________

Special Dietary Concerns or Food Allergies:

(Please note if epi-pen is required):

_______________________________

_______________________________

_______________________________

Physical Handicaps or Special Conditions:

______________________________

Check any health issues your child has:

___Asthma ___Seizures ___Nosebleeds

___ Headaches ___Diabetes

___Heart Murmur ___Sleepwalking

___ADD/ADHD

Other, Please Explain ______________________________________________________________

Parent’s Contact Information:

MOM DAD

Home: ____________ Home: ___________

Cell: _____________ Cell: _____________

Work: ____________ Work: ___________

Family Physician: __________________

Clinic: __________________________

Insurance Company: ________________

Policy # _______________________________

Member’s Name _______________________________

 

Medication & Health Information for us about your

child…

Child’s Name: ______________

Birthday: ___________

Grade Completed: _________

Age: ___ Weight: ___

 

Current Meds:

All medications brought to camp, both prescription and non-prescription, must be in the original containers and clearly labeled with camper’s name. All prescription medications will be dispensed according to the physician’s instructions on the bottle, unless a physicians order is attached. Please list all medications brought by the camper to be taken and mark your choices of time as listed.

MEDICATION

______________________________________________________________________________________________________________________________________________________________________________________

Please send more than the exact amount of medicine to camp. Send at

least one or two extra of each medicine.

By signing the line below, I give permission for my child to receive any of the following first aid and over-the-counter medications according to the specific directions on the product label by age or weight unless otherwise directed by a physician. NO MEDICATION WILL BE GIVEN WITHOUT PARENTAL PERMISSION.

*Tylenol (Acetaminophen)*Sunscreen Lotion *Motrin (Ibuprofen) *Aloe Vera *Chewable Pepto *Insect Bite relief *Imodium Liquid *Insect Repellant *Benadryl *Neosporin *Calamine Lotion *Rubbing Alcohol *Hydrocortisone Cream *Benadryl Cream *Hydrogen Peroxide *Cough Drops

Please indicate anything that you do NOT want given to your child.

____________________________________________________________________________________________________

DOSAGE

______________________________________________________________________________________________________________________________________________________________________________________    

                 X__________________________  

                 Parent  Signature       Date                                            By signing you are verifying all instructions for medications.

TIMES

______________________________________________________________________________________________________________________________________________________________________________________

*B=Breakfast 8am *S1=Snack 1 3:30pm *L=Lunch 12:30pm *S2=Snack 2 8:30pm *D=Dinner 6pm *BT=Bedtime 10:30pm

If you are allergic to bees, let us know if

you keep an epi-pen!!