Camper Health 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 1

Child 1's Full Name*

First Last

Child 1's Date of Birth*

Child 1's Gender*

Child 1's Grade (Fall 2021)*

Date of Child 1's Last Physical*

Date of Child 1's Current Tetanus*

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.

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.

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 2

Child 2's Full Name*

First Last

Child 2's Date of Birth*

Child 2's Gender*

Child 2's Grade (Fall 2021)*

Date of Child 2's Last Physical*

Date of Child 2's Current Tetanus*

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.

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.

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 3

Child 3's Full Name*

First Last

Child 3's Date of Birth*

Child 3's Gender*

Child 3's Grade (Fall 2021)*

Date of Child 3's Last Physical*

Date of Child 3's Current Tetanus*

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.

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.

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 Information

Family Address*

Street Address Address Line 2 City 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 Number

Parent/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*

Authorization

I understand that my child(ren) will not be able to attend CampJCC without having a Health Form on file.*

Yes

Patient 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.*

Yes

Signature of Parent/Guardian (person filling out this form)*

Full Name

Date*

JCC Indianapolis Together, we inspire all people to become the best versions of themselves

CampJCC Health and Medical Form: Grades K-6 and Sports

Child 1

Child 2

Child 3

Contact Information

Authorization