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Health Clearance (FINAL)

This health clearance form requests information about a camper's medical history and current health conditions. Parents are asked to disclose if the camper has a history of any medical issues and to explain any checked boxes. They must also confirm if the camper is free from contagious diseases, list any devices or splints, medications brought to camp and dosing instructions, allergies and reactions, and any other health problems or recent medical care. The form concludes with the parent's name, relationship, signature and date.

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Mary Therese Gabrielle Estioko
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8 views1 page

Health Clearance (FINAL)

This health clearance form requests information about a camper's medical history and current health conditions. Parents are asked to disclose if the camper has a history of any medical issues and to explain any checked boxes. They must also confirm if the camper is free from contagious diseases, list any devices or splints, medications brought to camp and dosing instructions, allergies and reactions, and any other health problems or recent medical care. The form concludes with the parent's name, relationship, signature and date.

Uploaded by

Mary Therese Gabrielle Estioko
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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BLD Baguio Youth Camp 2013

Health Clearance
Please submit this upon registering at the campsite.
CAMPERS NAME
1. Does the camper have a history of: (check all that apply)
Asthma Heart trouble Kidney/Bowel Disorder
Bleeding/Easy bruising Hypoglycemia/Diabetes Liver Disorder
Bone/Muscle/Joint Disorder Sore Throat Lung Disease
Ear Infection Menstrual Problems Skin Diseases
Fainting Motion Sickness Sleepwalking
Headaches Seizures
*Please attach a separate sheet of paper for explanation of any checked boxes if needed.
2. Camper is free from contagious health problems: ___Yes ___No
3. Please list any removable devices/splints, etc.


4. While at camp, will the camper be taking any medications? ___Yes ___No
If yes, please list all medications he/she will bring to camp and as to when the camper is
supposed to take these.



5. List all allergies (with the type of reaction experienced and treatment required):



6. List any other health-related problems, including medical care within the past six (6) months.





Parent/Guardians Name: Relationship:
Parent/Guardians Signature: Date:

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