SOLID ROCK BIBLE CAMP SUMMER CAMPER HEALTH FORM

Please print out this form and  bring it with you to registration or mail to:

36251 Solid Rock Road # 1, Soldotna AK 99669, or fax to 907-262-9088.

 

Camp Name & Date registered for:                                                                 Counselor:__________________________

                                                                   ___________________________________Cabin/Wagon:______________________

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Name:                                                                                     DOB:                                      Age at Camp:________________________ Home address:________________________________________________________________________________________

Parent/Guardian:                                                                                                  Home phone:_______________________________

Cell phone:                                                                            Work phone:______________________________________________

EMERGENCY CONTACT:                                                                                                Home phone:________________________

Cell phone:                                                                            Work phone:______________________________________________

Relationship to camper:_________________________________________________________________________________

 

Is camper covered by medical insurance?  Yes/No                                       Carrier’s Name:_____________________________

Phone number:                                                                                                     Policy number:______________________________

Name of family physician:                                                                                  Phone number:______________________________

Name of family dentist:                                                                                       Phone number:______________________________

 

GENERAL HEALTH  QUESTIONS

Has/does the camper:

 1. Had any recent injury or  illness? Yes/No                   12.  Ever had a head injury?                               Yes/No

 2. Ever had frequent ear infections?                Yes/No                   13.  Ever had high blood pressure?                   Yes/No

 3. Have any skin problems?                              Yes/No                   14.  Have asthma?                                                Yes/No  

 4. Have problems w/sleepwalking?                  Yes/No                   15.  Ever had emotional difficulties for which

 5. Have a chronic or recurring illness?            Yes/No                                   professional help was sought?          Yes/No

 6. Wear glasses or contacts?                            Yes/No                   16.  Ever had seizures?                                        Yes/No

 7. Have an orthodontic appliance?                  Yes/No                   17.  Have diabetes?                                              Yes/No

 8. Had mono in the last year?                            Yes/No                   18.  Have a history of bed wetting?                  Yes/No

 9. Have frequent headaches?                            Yes/No                   19.  Allergies/Reactions?                                    Yes/No

10. Immunizations current?                 Yes/No                   20.  Any current medications?                           Yes/No

11. Have frequent stomach aches?                   Yes/No

Please explain any “Yes” answers from above:

 

ESSENTIAL MEDICAL INFORMATION FOR CAMPERS

For the safety of everyone in camp and to comply with regulations, all medications will be stored in the Health Center.

Please do not send over the counter medications with your child.  The following over the counter medications are kept in the Health Center and are provided to campers under the Standing Orders provided by a local physician.  Those would include: Acetaminophen, Ibuprofen,  Robitussin DM, Sudafed, Tums, Mylanta, and Benedryl.

All prescription medications & vitamins must be in the original  container with the correct name, date, physicians name, and instructions on the bottle.  The camp will not administer any prescribed medications that are improperly

       labeled.  Phone calls will be made to parents and/or physicians concerning any medications about which there are any questions.

 

PERMISSION TO PROVIDE NECESSARY TREATMENT OR EMERGENCY CARE

I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment; to

release any records necessary for insurance purposes and to provide or arrange necessary related transportation for me or my child.  In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization for the person named above.  This completed form may be photocopied for trips out of camp.

 

Signature of Parent/Guardian:                                                                                                            Date signed:____________________

 

Signature of Camp Nurse/Medical Staff:                                                                                          Date signed:____________________

 

****If medical issues need to be discussed, please see Medical Staff during Camp Registration.****