Has this person ever required any psychiatric counseling or hospitalization?

Operations or serious injuries (dates):

Disability or chronic or recurring illness:

Any specific activities to be encouraged or limited by physician's advice:

Dietary modifications:

Current Medication (send with instructions):

Other diseases or details of above:

Date of last physical examination (mm/dd/yyyy):

Do you carry family medical/hospital insurance? Yes   No   If so, indicate:

Suggestions or health related information for camp personnel:

(For Female): Has this person menstruated? Yes   No

If not, has she been told about it? Yes   No

If so, is her menstrual history normal? Yes   No

Special Consideration:

IMMUNIZATION HISTORY - Please record the date (month and year) of basic and most recent booster dosages:

ALL IMMUNIZATIONS ARE UP TO DATE AS OF THE SIGNATURE DATE (Please check if this applies)

This health history is correct so far as I know, and the person listed above has permission to engage in all prescribed camp activities except as noted. I hereby give permission to the camp: to provide ongoing health care and to select medical personnel and to order X-rays or routine tests or treatment for the person listed above. Emergency Authorization: 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 injections and/or anesthesia and/or surgery for the person named above. I also understand and agree to abide with the restrictions placed on my camp activities. This form may be photocopied for use out of camp.

By checking the box you are agreeing to the terms above

Name of person filling out this form: