Youth Camp Health History

THIS HEALTH FORM IS REQUIRED FOR ALL CAMPERS

Camper #1
Camper 1 Name:*
Current residence:*
Street Address Address Line 2 City State ZIP Code
Emergency Contact

(Parent or Legal Guardian)
Phone:
2nd Emergency Contact:

(Other than Parent Above)
Phone:
Primary Care Physician

(Other providers of medical care)
Phone:
Camper #1 Health Information
Bee Sting Allergy?
Other Allergies?
Date Of Last Tetanus?
MM slash DD slash YYYY
Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?
Camper #1 Immunization Information
(Must list current residence above)
For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?
- NO
- YES
List immunization exceptions:
For campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896.
Add Another Camper?
- Yes
Signature
Camper #2
Camper 2 Name:*
Current residence:*
Street Address Address Line 2 City State ZIP Code
Emergency Contact

(Parent or Legal Guardian)
Phone:
2nd Emergency Contact:

(Other than Parent Above)
Phone:
Primary Care Physician

(Other providers of medical care)
Phone:
Camper #2 Health Information
Bee Sting Allergy?
Other Allergies?
Date Of Last Tetanus?
MM slash DD slash YYYY
Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?
Camper #2 Immunization Information
For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?
- NO
- YES
List immunization exceptions:
For campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896.
Signature*