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Child Health Form 2024
Emergency Contact Information: Please list in order at least 2 people who should be contacted in case of emergency – be sure to include Parents/Guardians
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Emergency Contact Information 1: Name
*
First
Last
Emergency Contact Information 1: Relationship
*
Emergency Contact Information 1: Cell Phone
*
Emergency Contact Information 1: Work Phone
*
Emergency Contact Information 1: Home Phone
*
Emergency Contact Information 2: Name
*
First
Last
Emergency Contact Information 2: Relationship
*
Emergency Contact Information 2: Cell Phone
*
Emergency Contact Information 2: Work Phone
*
Emergency Contact Information 2: Home Phone
*
Emergency Contact Information 3: Name
First
Last
Emergency Contact Information 3: Relationship
Emergency Contact Information 3: Cell Phone
Emergency Contact Information 3: Work Phone
Emergency Contact Information 3: Home Phone
Emergency Contact Information 4: Name
First
Last
Emergency Contact Information 4: Relationship
Emergency Contact Information 4: Cell Phone
Emergency Contact Information 4: Work Phone
Emergency Contact Information 4: Home Phone
Dietary Information
Vegetarian
Vegan
Lactose Intolerant
Gluten Free
Other
Please specify any other Dietary information
Allergies (Please be specific when completing the information requested below): Allergy Type (1)
Allergy types includes: Food, drug, insect, environmental, ect.
Allergen (1)
Please be specific ie. Bee sting, Red cedar trees
Type & severity of reaction (1)
Indicate if life threatening
Management/treatment/medication (1)
How can staff best manage an allergic reaction including any treatment and medication required
Date of last reaction (1)
Allergy Type (2)
Allergy types includes: Food, drug, insect, environmental, ect.
Allergen (2)
Please be specific ie. Bee sting, Red cedar trees
Type & severity of reaction (2)
Indicate if life threatening
Management/treatment/medication (2)
How can staff best manage an allergic reaction including any treatment and medication required
Date of last reaction (2)
Allergy Type (3)
Allergy types includes: Food, drug, insect, environmental, ect.
Allergen (3)
Please be specific ie. Bee sting, Red cedar trees
Type & severity of reaction (3)
Indicate if life threatening
Management/treatment/medication (3)
How can staff best manage an allergic reaction including any treatment and medication required
Date of last reaction (3)
Allergy Type (4)
Allergy types includes: Food, drug, insect, environmental, ect.
Allergen (4)
Please be specific ie. Bee sting, Red cedar trees
Type & severity of reaction (4)
Indicate if life threatening
Management/treatment/medication (4)
How can staff best manage an allergic reaction including any treatment and medication required
Date of last reaction (4)
Allergies: Does your child carry an Epinephrine/EpiPen?
Yes
No
Allergies: Does your child know how to self-inject the Epinephrine/EpiPen?
Yes
No
Asthma: Does your child suffer from Asthma?
Yes
No
Asthma: If Yes, indicate severity:
Mild
Moderate
Severe
Asthma: What are the triggers for an attack?
Asthma: Does your child carry an inhaler?
Yes
No
Level of Swimming
Dependent/Requires Life Jacket
Semi- independent/Requires Supervision
Independent/Swims Independently
Medications: Is your child currently on any medication (prescribed or homeopathic)?
Yes
No
If Yes, please complete and sign EFry Blue Sky Camp 2024 Medication Release Form identifying medication.
Health History: Please Check (√) if your child has had any of the following:
Chicken pox
Measles
Mumps
Hepatitis
Toothaches
Fractures
Strains/Sprains
Appendicitis
Tonsillitis
Migraines
Heart Condition
ADD/ADHD
Frequent Stomach Aches
Frequent Headaches
Epilepsy/Seizures
Fainting/Dizziness
Mononucleosis
Whooping Cough
Ear Trouble
Eye Trouble
Nosebleeds
Frequent Cold
Sinus Trouble
Lice
Other
If your child is currently subject or has previously been subject to any of the above, please give details. Does it affect their ability to participate in activities? If so, how?
Recent Health Concerns: Has your child experienced any recent hospitalizations, operations, serious illnesses/injuries or infectious diseases?
Yes
No
Recent Health Concerns: If Yes, please give date and details
Concerns/Comments: Is there anything else you feel is important that we should know about your child in relation to their participation in the Summer Camp Day Program?
By signing below, I attest to the truthfulness of all information listed on this health form and agree to all the above terms and conditions. I also acknowledge that I will notify the camp if there are any changes to my child’s health, or if he/she is exposed to any communicable diseases.
Parent/Guardian Signature (1): Print
*
Parent/Guardian Signature (1): Date
*
Parent/Guardian Signature (2): Print
*
Parent/Guardian Signature (2): Date
*
Submit
