Pathfinder Overnight CAMP

February 25 – 26, 2020

 CAMPER’S HEALTH FORM

NAME: ……………………………………………. D.O.B.: …………………………….

Address: ……………………………………………………………………………………….
CHURCH: ………………………………………………………………………………………
Parent/Guardian: …………………………………………………………………………

This form is to be filled out by the parent or guardian of the camper. The information given here
will be confidential.
A. What illness(es) your child has had: -
Mumps ___ Scarlet Fever ___
Whooping Cough ___ German Measles ___
Chicken Pox ___ Denque Fever ___
Measles ___ Sickle Cell ___
Rheumatic Fever ___

B. Put “Yes” or “No” where applicable:

The camper has been immunized against: (a) Diphtheria (___) (b) Polio (___) (c) Tetanus
(___)

The camper has the following:

Heart Problem __ High/Low Blood Pressure __
Asthma __ Hypoglycemia __
Bronchitis __ Joint Problems __
Diabetes __ Shortness of Breath __
Emotional Problems requiring medication __ Severe Headaches __
Epilepsy __ Severe Menstrual Cramps __
Fainting Spells __ Other Illnesses __

Please state any other information concerning your child’s health that you think your
Camp Nurse ought to know.
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

Are you currently taking any prescribed medication (including vitamins)? ( ) Yes ( ) No
If yes, please
state…………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………….

N.B. Please take with you all prescribed medication, Inhalers, Asthma pumps, etc. and
inform the relevant personnel.

Special treatment and pertinent information: ………………………………………………………………………

I have filled out this form myself and understand that the Camp Administration has taken
every precaution to see to my child’s welfare, and to encourage healthful habits during the
days of camp. I also understand that if medical expenses are incurred because of illness, I
will be responsible for such expenses.

…………………………………………….. ………………………………………………..
Date Signed: Parent/guardian

N.B. Forms must be filled out and returned along with camp application. No camp
application form will be accepted without the Campers Health Form being properly
filled out.