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_______________