Camper must submit this form at registration.
    Name
    Birth Date
    Sex
    Age
    Last
    First
    Middle Initial
    Home Address
    Home Phone (
    )
    Street & Number
    City
    State/ Zip Code
    Area
    Number
    Father’s Work Phone
    (
    )
    Mother’s Work Phone (
    )
    Cell Number (
    )
    Area
    Number
    Area
    Number
    Area
    Number
    Responsible Party or Custodial Parent
    Guarantor Name (Last, First, Middle)
    Guarantor home phone
    Relationship of camper to Guarantor
    Guarantor work phone
    Primary Insurance Co. Name
    Telephone (
    )
    Area
    Number
    Address
    Street & Number
    City
    State
    Zip
    Group Number
    Certificate/Policy Number
    Effective Date
    Campers relationship to insured
    Primary Care Physician
    Telephone (
    )
    Area
    Number
    List two other persons who would know where parents or a responsible party could be reached in case of emergency:
    1. Name
    Telephone (
    )
    Area
    Number
    2. Name
    Telephone (
    )
    Area
    Number
    HEALTH HISTORY: (Check “Yes” or “No” if your child has experienced any of the following . If “Yes”, give approximate date, or most recent date.)
    Yes No
    Date
    Ear Infection
    o
    o
    __________________
    Rheumatic Fever
    o
    o
    __________________
    Convulsions
    o
    o
    __________________
    Diabetes
    o
    o
    __________________
    Irregular Behavior
    o
    o
    __________________
    ALLERGIES
    Yes
    No
    Date
    Hay Fever
    o
    o
    __________________
    Poison Ivy, etc
    o
    o
    __________________
    Insect Stings
    o
    o
    __________________
    Penicillin
    o
    o
    __________________
    Other Drugs
    o
    o
    __________________
    DISEASES
    Yes
    No
    Date
    Chicken Pox
    o
    o
    __________________
    Measles
    o
    o
    __________________
    German measles
    o
    o
    __________________
    Mumps
    o
    o
    __________________
    Asthma
    o
    o
    __________________
    Other diseases or details of above
    Chronic or recurring illness
    Recent operations or serious injuries (include dates)
    IMPORTANT: Please notify the camp if this camper is exposed to any communicable disease during the three weeks prior to camp attendance.
    (over – WE MUST HAVE BOTH SIDES)
    CAMPER HEALTH INFORMATION FORM
    IMMUNIZATION HISTORY
    IT IS IMPORTANT THAT THIS BE COMPLETELY FILLED OUT OR C OPY OF IMMUNIZATION RECORD BE ATTACHED. PLEASE DO NOT
    LEAVE THIS BLANK OR WRITE SOME COMMENT SUCH AS “UP TO DATE.” Please give dates of basic immunizations and most recent
    booster doses.
    DPT Series
    Booster
    Tetanus Booster
    Typhoid (Must have date)
    Polio OPV (Sabin)
    Booster
    Measles vaccine (live)
    Tuberculin Test
    German Measles (Rubella)
    Mumps Vaccine (live)
    Smallpox
    Other
    RECOMMENDATIONS AND RESTRICTIONS WHILE IN CAMP
    Medicine to be given while at camp. MEDICATIONS BROUGHT TO CAMP MU ST BE IN ORIGINAL CONTAINER WITH INSTRUCTIONS ATTACHED AND
    GIVEN TO THE CAMP HEALTH CARE PROVIDER UPON ARRIVAL.
    Name of medication
    Times to be given
    Possible side effects
    Name of medication
    Times to be given
    Possible side effects
    Name of medication
    Times to be given
    Possible side effects
    Special Diet
    Check activities to be restricted:
    o
    Hiking
    o
    Swimming
    o
    Boating
    o
    Riflery
    o
    Climbing
    o
    Running
    o
    Softball
    o
    Water games
    All boating instructions will be under the su pervision of competent and qualified lifeguards. A camper does not go on the water until he/she has been
    instructed both in boating and water safety, and he/she must wear a life jacket.
    Participation in waterfront activities will be on the basis of swimm ing ability. Each child will be given an opportunity to demonstrate swimming abilities
    upon arrival at camp. Competent trained instructors will lead other activities. A camper’s safety is always the main concern of our staff.
    PARENT’S AUTHORIZATION
    This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed
    activities, except as noted.
    In the event 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, and to order injection, anesthesia or surgery for my child as named above.
    I authorize the release of medical information to the health plan indicated or
    f information requested by the health plan to
    determine the payment of medical benefits.
    Signature of responsible party or custodial parent _______________________________________ Date ______________________
    **Photography Release: I understand that promotional photographs or videos may be taken
    during the camp. Permission is granted for photography or video to be used by the BGCO for
    promotional purposes only.
    Signature ____________________ Date_______________

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