Registration Form

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Central California District

2018 HIGH SCHOOL CAMP JUNE 11 – JUNE 15 Camper Registration Form Camper's Name: __________________________________________________ Phone: (______)___________________ Gender: __________ Age: __________ DOB: __________/__________/__________ Last Grade Completed: _________ Mother/Guardian: _________________________________________________ Phone: (______)___________________ Email: _______________________________________________________ Preferred Contact Method: Phone Email Text Father/Guardian: __________________________________________________ Phone: (______)___________________ Email: _______________________________________________________ Preferred Contact Method: Phone Email Text Home Address: ___________________________________________________________________________________ Street

City

State

Zip

Emergency Contact: _______________________________________________ Phone: (______)___________________ Church Name: _____________________________________________________________________________________ Health History Is the camper up to date on Immunizations: YES / NO / NA Circle all that apply:

ADD

ADHD

Heart Condition

Seizures

Diabetes

Severe Allergy

*Asthma

Other

_________________________________________________________________________________________________ _________________________________________________________________________________________________ *All individuals with ASTHMA must bring an inhaler* Does the camper have any allergies or sensitivities to medications, food, or environmental: YES / NO _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Any camp activity restrictions (including swimming): YES / NO _______________________________________________ _________________________________________________________________________________________________ In the last 12 months, has the camper been seen by a professional for emotional or mental health concerns: YES / NO Has there been any life events that continue to affect the camper: YES / NO ____________________________________ _________________________________________________________________________________________________ Has the camper ever spent the night in the hospital: YES / NO Any other concerns that might come up at camp (bed wetting, bad dreams, sleep walking, etc.): YES / NO _________________________________________________________________________________________________

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Camper's Name: ______________________________________________ DOB: __________/__________/__________

Does the camper take any prescription medication, over the counter medication, or supplements: YES / NO *All medications the camper brings to camp must be in its original labeled container*

List medication that the camper will be taking while at camp: “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. All medications the camper brings to camp must be in its original labeled container. Please provide enough of each medication to last the entire time the camper will be at camp. Name of medication

Date Started

Reason for taking it

When it is given

How it is given

The following non-prescription medications may be stocked in the Camp Health Center and are used on an as needed basis to manage illness and injury. Please place an X on each item that is approved to give to the camper. ___Tylenol ___Advil ___Benadryl ___Zantac ___Claritin ___Zyrtec

___Tums ___Gas-X ___Mucinex ___Robitussin ___Cough Drops ___MiraLAX

___Imodium ___Maalox ___Dramamine ___Aloe Vera ___Burn Cream ___Calamine Lotion

___Hydrocortisone Cream 1% ___Antibiotic Ointment ___Lice Shampoo ___Swimmers Ear Drops

*Medication may be brand name or generic equivalent*

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. CCD Camp Insurance is secondary insurance. If you have medical insurance, your carrier will be billed for medical charges first in case of illness or injuries while at camp. Please complete the information below. Insurance Company: _____________________________________________________ Policy # ___________________ Policy Holder's Name: ____________________________________________________Group # ___________________ Camper’s Physician Name: _________________________________________ Phone# (______)___________________ Parent/Guardian Signature: _________________________________________________ Date: ____________________ Camper Signature: _______________________________________________________ Date: ____________________ Page | 2 of 2