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Camp Good News Medical Questionarie
Camp Good News Medical Questionarie
Name of Camper:
First
Last
Age at Camp:
Please enter a number from
2
to
25
.
Birth Date:
MM slash DD slash YYYY
Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Parent/Legal Guardian Name:
First
Last
Phone #:
Additional Emergency Contact:
First
Last
Phone #:
Name of Camper's Insurance
Policy Number
Group Number If applicable
Does the camper have : (select all that applies)
Diabetes
Yes
No
Special Diet
Yes
No
Special Diet if yes, what is it?
Hypoglycemia
Yes
No
Asthma
Yes
No
Hay Fever
Yes
No
Has the applicant had:(circle answer)
Allergy or serious reaction to bee sting ?
Yes
No
Allergies to Medication
Yes
No
Allergies to Medication If yes, what meds?
Allergies to food ?
Yes
No
Allergies to food If yes, name the foods ?
Chicken Pox
Yes
No
Rheumatic Fever
Yes
No
Mumps
Yes
No
Rubella
Yes
No
German Measles
Yes
No
Measles
Yes
No
Has the camper had any illness requiring a visit to the doctor in the last 3 months?
Yes
No
If yes, indicate special attention needed(camper illness)?
Does camper have any health conditions or physical challenges that would require special services?
Yes
No
If yes, please indicate types of services needed.
Use Inhaler?
Yes
No
Use Inhaler if yes, How often?
Carry an EPIPEN?
Yes
No
Carry an EPIPEN if yes, explain
Please list any non-prescription drugs that you would allow your camper to take at his/her discretion, (i.e:Tylenol, aspirin, Ibuprophen, antihistamine, cold/cough medicine, etc.)
Campers Insurance file Upload
Drop files here or
Select files
Accepted file types: jpg, gif, pdf, png, Max. file size: 4 MB, Max. files: 4.
Please list ALL prescription drugs being brought by the camper:
NOTE:
All medications must be in their original containers, must be in a labeled zip lock bag, and must be turned into the Camp Good News nurse at registration. No medication of any kind will be allowed in the cabin without the knowledge and approval of the Camp Good News Director AND Nurse.
PARENTAL/GUARDIAN PERMISSION
I,
,parent/guardian of
hereby authorize the nurse on duty at Camp Good News to serve on loco parentis for me in giving the following over-the-counter medication to my son or daughter: Tylenol (acetaminophen) or Advil (Ibuprofen) for pain, Tums (antacid) for upset stomach, or other over-the-counter medications that i have supplied for my son or daughter. I authorize the Camp Director, the Child Evangelism fellowship (CEF) State Director , and the nurse on duty to serve in loco parentis for me in talking my son or daughter to a doctor or emergency room for any urgent need with the understanding that the i will be notified as soon as possible.
Signed
Date
LIABILITY AND RESPONSIBILITY CLAUSE
Child Evangelism Fellowship is not responsible for any medical bills incurred while my child serves as camp counselor at Camp Good News. I agree to use my own medical insurance as a primary coverage in the event that my child needs medical care. I understand that i, the parent or guardian, will be responsible for any medical bills for mu child and will make sure all medical bills are paid for in full.
Signed
Date
Please make
a copy of both sides of camper's insurance
card and include with this form.
Form is signed.
(By checking this box) I hereby certify that, to the best of my knowledge, the provided information is true, accurate and signed.
(By checking this box) I acknowledge that both sides of the camper’s insurance have been photographed and included with this form.
Post Body