Pleasant Bay Camp :: Camper Health Form

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Please complete the information below so that we may assist your child to have a fantastic week at camp.

Camper Health Form

*	First Name:
*	Last Name:
*	Address:
*	City:
*	State/Province:
*	Zip/Postal Code:
*	Email Address:
*	Phone:
*	What week(s) are you attending camp?	July 7-13 July 14-20 July 21-2 July 28-August 3 August 4-10 (ages 13-17) August 11-17 (ages 13-17)
*	Please enter your birthday in the order of month/day/year.
*	Please enter your health insurance number.
	Please indicate any other type of insurance coverage and provide the suitable information/number.
*	Please write the name of your family doctor and their phone number.
*	Who does the camper live with?	parents foster parents mother father guardian grandparents
*	Please enter the name of the parent/guardian?
*	In case of emergency or illness please contact......(include name, phone and relationship please)
*	If they are unavailable please contact...(include name, phone and relationship please)
* Will medication be required at camp? yes no
	If yes, please describe the medication, its purpose and how it is to be administered.
	Does the camper have any of the following?	Food Restrictions or Issues Heart Trouble Asthma Diabetes Convulsions Bedwetting Nightmares/Sleepwalking Headaches/Earaches/Sore Throat Upset Stomach Fainting Past Operations Serious Injury
	Please comment if you have answered yes to any of the above.
	Does the camper have any physical, mental or emotional weakness or disability, chronic condition or recent illness which the staff should be aware of that may require attention?
* Has the camper had any recent exposure to infectious disease? yes no
* Does the camper have any allergies? yes no
	If the camper has allergies please list them, describe the type and severity of the reaction as well as the treatment given.
* Are the camper's immunizations up to date? yes no
*	Does the camper have any restrictions on swimming or other camp activities?
* By completing this form and submitting it, I authorize the camp nurse and/or director.. to secure medical advice and services as may be deemed necessary for the camper's health and safety.
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