Camper Health Form and Medication Authorization Intake

Collects health history, immunization records, allergies, and parent/guardian-signed authorization to administer medication at camp. Designed for camp health supervisors to comply with state youth camp licensing requirements and ACA (American Camp Association) standards.

Submission Notice and Privacy Disclosure

• I have read and understand the privacy disclosure above
• Camp Session
• Session Start Date

Camper Information

• Camper First Name
• Camper Last Name
• Date of Birth
  Used to verify age eligibility and calculate appropriate medication dosages.
• Gender Identity
  Optional. Used to inform health care delivery.
• Self-described gender identity
• Cabin / Group Assignment (if known)

Parent / Guardian Information

• Parent / Guardian Full Name
• Relationship to Camper
• Describe relationship
• Primary Phone Number
• Secondary / Alternate Phone Number
• Email Address
• Emergency Contact Name (if different from above)
• Emergency Contact Phone
• Emergency Contact Relationship to Camper

Health Insurance Information

• Does the camper have health insurance?
• Insurance Carrier / Plan Name
• Policy / Member ID Number
  Do not include full SSN. Member ID only.
• Group Number (if applicable)
• Upload Insurance Card (front and back)
  Optional but recommended. Upload a photo of both sides of the insurance card.

Physician / Healthcare Provider

• Physician / Provider Name
• Practice / Clinic Name
• Physician Phone Number

Immunization History

• Are the camper's immunizations up to date per the CDC recommended schedule?
• If not up to date, reason
• Additional details about immunization status
• Year of Most Recent Tetanus / Tdap Booster
• Upload Immunization Records
  Attach official immunization records if available.

Allergies and Reactions

• Does the camper have any known allergies?
• Allergy categories (select all that apply)
• Describe each allergy, the reaction it causes, and its severity
  Example: Peanuts — anaphylaxis (carries EpiPen); Penicillin — hives; Bee sting — localized swelling only.
• Does the camper carry an epinephrine auto-injector (EpiPen)?
• Upload Allergy / Anaphylaxis Action Plan (if applicable)
  Physician-signed action plan recommended for any camper with anaphylactic risk.

Medical History

• Does the camper have any current or ongoing medical conditions?
• List all current medical conditions and any relevant history
  Include diagnoses such as asthma, diabetes, epilepsy, cardiac conditions, or any condition requiring monitoring or treatment at camp.
• Has the camper had any illness, injury, or surgery in the past 12 months?
• Describe the illness, injury, or surgery and current status
• Are there any physical activity restrictions or limitations?
• Describe activity restrictions and any physician instructions
• Does the camper have any mental health, behavioral, or developmental conditions the health staff should be aware of?
• Describe the condition and any accommodations or support strategies that are helpful
  This information is confidential and shared only with health and program staff on a need-to-know basis.

Current Medications

• Is the camper currently taking any medications (prescription or OTC)?
• Medication List
  List each medication the camper takes. All medications must arrive in original labeled containers.
• Special storage or handling instructions for any medication

Medication Administration Authorization

• I authorize camp health staff to administer the prescription medications listed above according to the labeled instructions
• I authorize camp health staff to administer the following OTC medications as needed for minor illness or discomfort
  Select all OTC medications you authorize. Selecting none means no OTC medications will be given without direct parent contact.
• Are there any OTC medications the camper must NOT receive?
• I authorize camp health staff and emergency medical personnel to obtain emergency medical treatment for my camper if I cannot be reached in a timely manner
• Preferred hospital or medical facility (if any)

Dietary and Additional Needs

• Does the camper have dietary restrictions or special food needs?
• Describe dietary restrictions or needs
• Additional dietary details or instructions for kitchen staff
• Any other health, behavioral, or personal care information the health staff should know?
  Include information about sleep issues, homesickness history, sensory sensitivities, toileting needs, or anything else relevant to your camper's care.

Parent / Guardian Signature and Certification

• I certify that the information provided in this form is accurate and complete
• I certify that I am the parent or legal guardian of this camper and am authorized to consent to medical treatment on their behalf
• Date of Signature
• Parent / Guardian Signature
  Draw or type your signature to authorize this form.
• Printed Name of Parent / Guardian