Rosmarin's Health Form

Camper Health History Form

Camper's Last Name	Camper's First Name
A value is required.	A value is required.

A value is required. A value is require

Address A value is required.
City A value is required. State A value is required. Zip A value is required.Invalid format.

Parent/guardian with legal custody to be contacted in case of illness or injury:

Name A value is required.
A value is required.

Relationship to Camper

Preferred Phone 1 A value is required. Preferred Phone 2

Email A value is required.Invalid format.
Home Address State Zip

Second Parent/guardian or other emergency contact:

Name: Relationship to Camper

Preferred Phone 1: Preferred Phone 2:

Email: Invalid format.

Additional Parent/guardian or other emergency contact:

Name: Relationship to Camper

Preferred Phone 1: Preferred Phone 2:

Email: A value is required.Invalid format.

Allergies
No known allergies
This camper is allergic to: Food Medicine Enviroment (insect stings, hay fever, etc) Other

(Please describe below what the camper is allergic to and the reaction seen.)

Diet Nutrition
This camper eats a regular diet.
This camper eats a regular vegetarian diet.
This camper has special food needs.

(Please describe below)

Restrictions
I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations.

(Please describe below)

Medical Insurance Information
This camper is covered by family medical/hospital insurance Yes No

Fax a copy of your insurance card if appropriate; copy both sides of the card so information is readable.

Insurance Co.	Policy Number
Subscriber	Insurance Co. Ph#

Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my
permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child 's health record from providers who treat my child and these providers may talk with the program's staff about my child 's health status.

Signature of Custodial
Parent/Guardian A value is required. Date
Relationship to Camper

If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance.

Camper Health History

General Health History:
Check "Yes" or "No" for each statement. Explain "Yes" answers below.
Has/does the camper:

1.	Ever been hospitalized?	Yes	No
1.	If Yes, Please Explain
2.	Ever had surgery?	Yes	No
	If Yes, Please Explain
3.	Have recurrent/chronic illnesses	Yes	No
	If Yes, Please Explain
4.	Had a recent infectious disease?	Yes	No
	If Yes, Please Explain
5.	Had a recent injury?	Yes	No
	If Yes, Please Explain
6.	Had asthma/wheezing/shortness of breath?	Yes	No
	If Yes, Please Explain
7.	Have diabetes?	Yes	No
	If Yes, Please Explain
8.	Had seizures?	Yes	No
	If Yes, Please Explain
9.	Had headaches?	Yes	No
	If Yes, Please Explain
10	Wear glasses, contacts, or protective eyewear?	Yes	No
	If Yes, Please Explain
11.	Had fainting or dizziness?	Yes	No
	If Yes, Please Explain
12.	Passed out/had chest pain during exercise?	Yes	No
	If Yes, Please Explain
13.	Had mononucleosis ("mono") during the past 12 months?	Yes	No
	If Yes, Please Explain
14.	If female, have problems with periods/menstruation?	Yes	No
	If Yes, Please Explain
15.	Have problems with falling asleep/sleepwalking?	Yes	No
	If Yes, Please Explain
16.	Ever had back/joint problems?	Yes	No
	If Yes, Please Explain
17.	Have a history of bedwetting?	Yes	No
	If Yes, Please Explain
18.	Have problems with diarrhea/constipation?	Yes	No
	If Yes, Please Explain
19.	Have any skin problems?	Yes	No
	If Yes, Please Explain
20.	Traveled outside the country in the past 9 months?	Yes	No
	If Yes, Please Explain For travel outside the country, please name countries visited and dates of travel here.

Mental, Emotional, and Social Health

Check "Yes" or "No" for each statement.
Has the camper:

1.	Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?	Yes	No
	If Yes, Please Explain
2.	Ever been treated for emotional or behavioral difficulties or an eating disorder?	Yes	No
	If Yes, Please Explain
3.	During the past 12 months, seen a professional to address mental/emotional health concerns?	Yes	No
	If Yes, Please Explain
4.	Had a significant life event that continues to affect the camper's life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)	Yes	No
	If Yes, Please Explain

Health Care Providers

Name of camper’s primary doctor(s):		Phone:
Name of dentist(s):		Phone:
Name of orthodontist(s):		Phone:

What Have We Forgotten to Ask?
Please provide in the space below any additional information about the camper's health that you think important or
that may affect the camper's ability to fully participate in the camp program. Attach additional information if needed.

Parents/Guardians: STOP here.
Please click Here to download and print the Immunization History and fill out completely
You may also have your child's health care provider Fax copy to 845-782-7038 or
Scan & Email to rosmarin57@optonline.net