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Run: Camper Health Form and Medication Authorization Intake

Collect camper health history, immunization records, allergies, and signed medication authorization in one camp intake form. Built to help camp health superv...

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Submission Notice and Privacy Disclosure

I have read and understand the privacy disclosure above (required)

Yes No N/A

Camp Session (required)

Session Start Date (required)

Camper Information

Camper First Name (required)

Camper Last Name (required)

Date of Birth (required)

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 (required)

Relationship to Camper (required)

Describe relationship

Primary Phone Number (required)

Secondary / Alternate Phone Number

Email Address (required)

Emergency Contact Name (if different from above)

Emergency Contact Phone

Emergency Contact Relationship to Camper

Health Insurance Information

Does the camper have health insurance? (required)

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? (required)

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? (required)

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? (required)

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? (required)

Describe the illness, injury, or surgery and current status

Are there any physical activity restrictions or limitations? (required)

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? (required)

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)? (required)

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 (required)

I authorize camp health staff to administer the following OTC medications as needed for minor illness or discomfort (required)

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 (required)

Preferred hospital or medical facility (if any)

Dietary and Additional Needs

Does the camper have dietary restrictions or special food needs? (required)

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 (required)

Yes No N/A

I certify that I am the parent or legal guardian of this camper and am authorized to consent to medical treatment on their behalf (required)

Yes No N/A

Date of Signature (required)

Parent / Guardian Signature (required)

Draw or type your signature to authorize this form.

Printed Name of Parent / Guardian (required)

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Email (required)

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