Camper Health Form CampJCC Health and Medical Form: Grades K-8 and Sports Up to three children may be listed on this form. How many children will be listed on this form?*This will allow us to show as many fields as you need. One Two Three Child 1Child 1's Full Name* First Last Child 1's Date of Birth* MM slash DD slash YYYY Child 1's Gender* Child 1's Grade (Fall 2022)* Date of Child 1's Last Physical* MM slash DD slash YYYY Date of Child 1's Current Tetanus* MM slash DD slash YYYY Child 1's School/Child Care attended prior to this summer* Immunizations* Child 1's immunizations are up-to-date and on file at Child 1's school.Is Child 1 vaccinated against COVID-19?* Yes No Please provide a copy of the vaccination certificate Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 50 MB. Does Child 1 have any allergies (food, insects, medication, etc.?)* Yes No Please explain:*Are there any concerns about Child 1's general health (eating and sleeping habits, asthma, weight, etc.)?* Yes No Please explain:*Does Child 1 have any problems with vision, hearing or speech (does Child 1 wear glasses, contacts, ear tubes or hearing aids)?* Yes No Please explain:*Does Child 1 take any over-the-counter or prescription medication (daily or occasionally) or use an insulin pump?*Prescription drugs must be in the original pharmacy bottle, including the time the medication is to be administered. All medications taken during camp hours, whether prescription or over-the-counter, must be given directly to the CampJCC Director by a parent (please do not send with camper). Yes No Please explain, and list any medication Child 1 will need during program hours, including the medication name, dosage and time(s) to be administered*Medications that are to be administered during program hours must be given directly to the Director by a parent/guardian (please do not send with child). Medications should be in the original container, accompanied by written prescription and clearly labeled with Child 1's name, directions, parent/guardian's name and phone number and physician's name and phone number. To keep all medications safe, counselors will carry any medications that are for immediate need (inhaler, Epi-Pens, etc.). If there are any concerns, CampJCC staff are open to discussing how to give medication with you prior to the first day your child attends camp. Please do not send campers to camp with over-the-counter medications (aspirin, ibuprofen, cough drops, etc.). If you want your child to have access to these medications during camp hours, please follow the same steps as medications with prescriptions (give directly to the Director).Child 1 will be wearing:* Eyeglasses Contact lenses Braces Hearing aid(s) Insulin pump None of the above Child 1 receives/has:* Speech services Occupational therapy Physical therapy None of the above Please explain:*Child 1 receives/has:* An IEP/504 plan Early intervention services Behavior Intervention Planning Social skills training None of the above Please explain:*A copy of the plan must be provided to the CampJCC director prior to May 22. This will help us ensure the most successful experience for your child this summer.You may upload the plan here: Drop files here or Select files Accepted file types: pdf, Max. file size: 50 MB. Does Child 1 have any other specific illnesses, social/emotional challenges or behavior problems?* Yes No Please explain:*Has Child 1 had any hospitalization, operation or major illness (specify problem)?* Yes No Please explain:*Has Child 1 had any significant injury or accident (specify problems)?* Yes No Please explain:*Would you like to discuss anything about Child 1's physical, mental or behavioral health with CampJCC staff?* Yes No Please explain:*Child 2Child 2's Full Name* First Last Child 2's Date of Birth* MM slash DD slash YYYY Child 2's Gender* Child 2's Grade (Fall 2022)* Date of Child 2's Last Physical* MM slash DD slash YYYY Date of Child 2's Current Tetanus* MM slash DD slash YYYY Child 2's School/Child Care attended prior to this summer* Immunizations* Child 2's immunizations are up-to-date and on file at Child 2's school.Has Child 2 been vaccinated against COVID-19* Yes No Please provide a copy of the vaccination certificate Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 50 MB. Does Child 2 have any allergies (food, insects, medication, etc.?)* Yes No Please explain:*Are there any concerns about Child 2's general health (eating and sleeping habits, asthma, weight, etc.)?* Yes No Please explain:*Does Child 2 have any problems with vision, hearing or speech (does Child 2 wear glasses, contacts, ear tubes or hearing aids)?* Yes No Please explain:*Does Child 2 take any over-the-counter or prescription medication (daily or occasionally) or use an insulin pump?*Prescription drugs must be in the original pharmacy bottle, including the time the medication is to be administered. All medications taken during camp hours, whether prescription or over-the-counter, must be given directly to the CampJCC Director by a parent (please do not send with camper). Yes No Please explain, and list any medication Child 2 will need during program hours, including the medication name, dosage and time(s) to be administered*Medications that are to be administered during program hours must be given directly to the Director by a parent/guardian (please do not send with child). Medications should be in the original container, accompanied by written prescription and clearly labeled with Child 2's name, directions, parent/guardian's name and phone number and physician's name and phone number. To keep all medications safe, counselors will carry any medications that are for immediate need (inhaler, Epi-Pens, etc.). If there are any concerns, CampJCC staff are open to discussing how to give medication with you prior to the first day your child attends camp. Please do not send campers to camp with over-the-counter medications (aspirin, ibuprofen, cough drops, etc.). If you want your child to have access to these medications during camp hours, please follow the same steps as medications with prescriptions (give directly to the Director).Child 2 will be wearing:* Eyeglasses Contact lenses Braces Hearing aid(s) Insulin pump None of the above Child 2 receives/has:* Speech services Occupational therapy Physical therapy None of the above Please explain:*Child 2 receives/has:* An IEP/504 plan Early intervention services Behavior Intervention Planning Social skills training None of the above Please explain:*A copy of the plan must be provided to the CampJCC director prior to May 22. This will help us ensure the most successful experience for your child this summer.You may upload the plan here: Drop files here or Select files Accepted file types: pdf, Max. file size: 50 MB. Does Child 2 have any other specific illnesses, social/emotional challenges or behavior problems?* Yes No Please explain:*Has Child 2 had any hospitalization, operation or major illness (specify problem)?* Yes No Please explain:*Has Child 2 had any significant injury or accident (specify problems)?* Yes No Please explain:*Would you like to discuss anything about Child 2's physical, mental or behavioral health with CampJCC staff?* Yes No Please explain:*Child 3Child 3's Full Name* First Last Child 3's Date of Birth* MM slash DD slash YYYY Child 3's Gender* Child 3's Grade (Fall 2022)* Date of Child 3's Last Physical* MM slash DD slash YYYY Date of Child 3's Current Tetanus* MM slash DD slash YYYY Child 3's School/Child Care attended prior to this summer* Immunizations* Child 3's immunizations are up-to-date and on file at Child 3's school.Has Child 3 been vaccinated against COVID-19?* Yes No Please provide a copy of the vaccination certificate Drop files here or Select files Accepted file types: pdf, jpg, png, Max. file size: 50 MB. Does Child 3 have any allergies (food, insects, medication, etc.?)* Yes No Please explain:*Are there any concerns about Child 3's general health (eating and sleeping habits, asthma, weight, etc.)?* Yes No Please explain:*Does Child 3 have any problems with vision, hearing or speech (does Child 3 wear glasses, contacts, ear tubes or hearing aids)?* Yes No Please explain:*Does Child 3 take any over-the-counter or prescription medication (daily or occasionally) or use an insulin pump?*Prescription drugs must be in the original pharmacy bottle, including the time the medication is to be administered. All medications taken during camp hours, whether prescription or over-the-counter, must be given directly to the CampJCC Director by a parent (please do not send with camper). Yes No Please explain, and list any medication Child 3 will need during program hours, including the medication name, dosage and time(s) to be administered*Medications that are to be administered during program hours must be given directly to the Director by a parent/guardian (please do not send with child). Medications should be in the original container, accompanied by written prescription and clearly labeled with Child 3's name, directions, parent/guardian's name and phone number and physician's name and phone number. To keep all medications safe, counselors will carry any medications that are for immediate need (inhaler, Epi-Pens, etc.). If there are any concerns, CampJCC staff are open to discussing how to give medication with you prior to the first day your child attends camp. Please do not send campers to camp with over-the-counter medications (aspirin, ibuprofen, cough drops, etc.). If you want your child to have access to these medications during camp hours, please follow the same steps as medications with prescriptions (give directly to the Director).Child 3 will be wearing:* Eyeglasses Contact lenses Braces Hearing aid(s) Insulin pump None of the above Child 3 receives/has:* Speech services Occupational therapy Physical therapy None of the above Please explain:*Child 3 receives/has:* An IEP/504 plan Early intervention services Behavior Intervention Planning Social skills training None of the above Please explain:*A copy of the plan must be provided to the CampJCC director prior to May 22. This will help us ensure the most successful experience for your child this summer.You may upload the plan here: Drop files here or Select files Accepted file types: pdf, Max. file size: 50 MB. Does Child 3 have any other specific illnesses, social/emotional challenges or behavior problems?* Yes No Please explain:*Has Child 3 had any hospitalization, operation or major illness (specify problem)?* Yes No Please explain:*Has Child 3 had any significant injury or accident (specify problems)?* Yes No Please explain:*Would you like to discuss anything about Child 3's physical, mental or behavioral health with CampJCC staff?* Yes No Please explain:*Contact InformationFamily Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Family Phone Number*Name of Family Physician* First Last Phone Number of Family Physician*Parent/Guardian #1 Name* First Last Parent/Guardian #1 Email* Parent/Guardian #1 Cell Phone Number*Parent/Guardian #1 Emergency Phone* Parent/Guardian #1 Emergency Phone Number (if different from cell)Parent/Guardian #2 Name First Last Parent/Guardian #2 Email Parent/Guardian #2 Cell Phone NumberParent/Guardian #2 Emergency Phone Parent/Guardian #2 Emergency Phone Number (if different from cell)Emergency Contact #1 Name* First Last Emergency Contact #1 Relationship to Child(ren)* Emergency Contact #1 Phone Number*Emergency Contact #2 Name* First Last Emergency Contact #2 Relationship to Child(ren)* Emergency Contact #2 Phone Number*AuthorizationI understand that my child(ren) will not be able to attend CampJCC without having a Health Form on file.* YesPatient Authorization: This health history provided herein is correct and complete in every sense. The child(ren) herein described has permission to engage in all program activities except as noted herein. I hereby give permission to the program to provide routine health care, administer prescribed medications and seek emergency medical treatment including x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the program to arrange necessary related transportation for the child(ren). In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the program to secure and administer treatment, including hospitalization, for the child(ren) named above.* YesSignature of Parent/Guardian (person filling out this form)* Full Name Date* MM slash DD slash YYYY Δ Share Facebook Twitter LinkedIn
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