Single Camper Medical/Medication Form

User information

• First name
• Last name
• Email
• Gender
• Birthday
• Address

Additional information

• Parent/Guardian First and Last Name
• Parent/Guardian Contact Number
• Please provide the best Emergency Contact (Full first and last name / Relationship to Camper). Example (John Doe / Uncle)
• Best Emergency Contact Phone Number(s) for Weekend of Event:
• Please provide the best Alternate Emergency Contact (Full first and last name / Relationship to Camper). Example (Jane Doe / Aunt)
• Best Alternate Emergency Contact Phone Number(s) for Weekend of Event:
• Please provide this camper's Primary Care Doctor Name / Primary Care Doctor Phone Number (example: Dr James Brown / 919-999-9999)
• Please provide the camper's Primary Care Doctor's Full Address (include street address, city, state, and zip code)
• Please provide the name of the camper's Health Insurance Company / Policy number (example: Blue cross and blue shield of North Carolina / Policy # 1234567)
• Upload a copy of your insurance card here:
• Primary Camper's Height/Weight/and Sex assigned at birth (example: 5'1" / 135 lbs / Female)
• Please list all allergies for the primary camper (medication allergies and general allergies). If none, type N/A:
• Has the Primay Camper ever been treated for: (If currently being treated please indicate)
• If the camper is currently being treated for any of the indentified medical conditions above, please elaborate on any medical accommodations that may be needed.
• Does your camper have any other physical limitations? Please describe if so:
• Please attach any additional medical information/documents that may necessary:
• Please list all prescription medications the Camper will need while attending camp. Information needed: Medication name Dosage Time of day given Please bring medications in the original bottles in a ziplock bag w/ campers name and date of birth (example: Zyrtec - 10mg - AM morning). If none, type N/A.
• Please check the medications you give your permission for your camper to have if needed:
• Any condition which is associated with fever, significant inflammation, and/or does not respond to the above outlined OTC treatment will be followed-up by a consultation with the Participant’s parent/guardian. I authorize the administration of checked OTC medications and Prescription medications to my child as indicated above and general first aid treatment.
• Please read carefully: I hereby certify that the information given above is correct. In case of a medical emergency, I understand that every effort will be made to contact the person designated above. In the event that person cannot be reached, or time does not permit, I hereby give permission to a licensed physician to provide proper treatment for, including hospitalization, immunization or injection, anesthesia or surgery for my child.