Camper Health History Form

Date camper will attend camp:

To Parent(s)/Guardian(s): Please follow the instructions below. Attached additional information if needed.

  1. Only ONE CAMPER per form!
  2. Complete pages 1, 2, and 3 of this form and make a copy
  3. Send the original, signed form to WeHaKee Camp for Girls by May 1st
  4. If your daughter has significant health issues that will directly impact her experience at camp, please
    contact the Directors at WeHaKee Camp for Girls.

Parent/Guardian with legal custody to be contacted in case of illness or injury:

Fill in your address information if different than above.

Second parent/guardian or other emergency contact:

Only provide Address/City/State/ZIP/Country if different than camper. Click on 'Parent 2 Address' to expand fields and fill in information, or to collapse fields after you've filled in the information.

Additional contact in event parent(s)/guardian(s) cannot be reached: Click on 'Additional Contact' to expand fields and fill in information, or to collapse fields after you've filled in the information.

Additional Contact
Alergies (please list all known)

Please be as precise as possible. For example: "If my daughter eats anything with nuts, she gets hives."

Diet Nutrition

Please be as precise as possible. For example: "My daughter needs to always have something with sugar with her to keep her blood sugar balanced."

Restrictions

Please be as precise as possible.

Medical Insurance Information

Send us a copy of your insurance card; copy both sides of the card so information is readable.

If the camper is covered by family medical/hospital coverage please fill out the rest of the medical information. If the camper is not covered, continue to the next section.

If for religious or other reasons you cannot sign this, contact WeHaKee Camp for Girls for a legal waiver that must be signed for attendance.

This health history is correct and accurately reflects the health status of the camper to whom it pertains. I attest that all of my child's immunizations required for school are up to date (unless clearly noted in the Immunization History of this form). The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, WeHaKee Camp for Girls has my permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

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