New Covenant Bible Church

Youth Camp Health Form

Camper Name: ______________________________________________________

Age: _____________________________ Gender: ________________________

HEALTH HISTORY

Does your child have any of the following?

Frequent Ear Infections -------------------------------------------------- YES NO

Heart Disease or Heart Problems --------------------------------------- YES NO

Diabetes ------------------------------------------------------------------- YES NO

Convulsion’s or Seizures ------------------------------------------------ YES NO

Hemophilia (Bleeding Disorder) --------------------------------------- YES NO

Nose Bleeds --------------------------------------------------------------- YES NO

Sickle Cell ----------------------------------------------------------------- YES NO

Bed Wetting --------------------------------------------------------------- YES NO

Asthma (Breathing Problems) ------------------------------------------ YES NO

Pregnancy ------------------------------------------------------------------- YES NO

Received Tetanus Shot in past 5 years ---------------------------------- YES NO

Please provide details of any health problems including year of Tetanus Shot:
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Camper Name: ________________________________

ALLERGIES

Food Allergies ------------------------------------------------------------------ YES NO

List Food Item Reaction
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To Poison Ivy, Poison Oak, Bee Stings ------------------------------------ YES NO

List Reaction
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Drug Allergy ------------------------------------------------------------------- YES NO

List Reaction
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Other Allergies ------------------------------------------------------------------ YES NO

List Reaction
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MEDICATIONS

Does your child take any medication? YES NO

Medication Name Reason How Much How Often

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Mediations While at Camp

Please make sure you have listed in the space provided above all medications that your child will be
bringing to camp. Medicine must be in the pharmacy labeled bottle with the correct camper’s name on it.
DO NOT SEND MEDICINE IN ZIP LOCK BAGS. Send enough medicine for the entire camp session.

Parent/Guardian Authorization: This health history is correct to my knowledge, and the camper listed
has permission to engage in all camp activities except as noted by me. I hereby give my permission to the
physician selected by the camp director to order x-rays, routine tests, and treatment for the health of my
child. If I cannot be reached in an emergency, I hereby give permission to the physician selected by the
camp director to hospitalize, secure proper treatment for, order injections and/or anesthesia and/or surgery
for my child as named above. I also give permission for the camp nurse to administer medication to my
child as needed.
Parent/Guardian Signature: ________________________________________ Date: ______________
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