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Camper Health History Form

Step 1 of 3

33%

Date camper will attend camp:
From
MM
DD
YYYY
To
MM
DD
YYYY
Camp Arrival Date
Date Format: MM slash DD slash YYYY
Camper's Full Name
Full, Middle, and Last
Gender
- Female
- Male
Camper Birthdate
MM
DD
YYYY
Age
To Parent(s)/Guardian(s):
Please follow the instructions below. 1. Only ONE CAMPER per form! 2. Complete this form and print a copy for your records (a copy will be e-mailed to the first and second parent/guardians listed on this form). 3. Submit this form 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.
Camper Information
Camper Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent/Guardian Information
Parent/guardian with legal custody to be contacted in case of illness or injury:
Parent/Guardian Full Name
Relationship to Camper
Preferred Phone 1
Preferred Phone 2
E-mail Address
Is your address different from your camper's address (entered above)?
- Yes
- No
Parent/Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Second parent/guardian or other emergency contact:
Check this box if this person has current legal custody of the above named child.
- Yes, this person has current legal custody of the above named child.
Full Name
Relationship to Camper
Preferred Phone 1
Preferred Phone 2
E-mail Address
Is your 2nd parent's address different from your camper's address (entered above)?
- Yes
- No
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Additional contact in event parent(s)/guardian(s) cannot be reached:
Name
Relationship to Camper
Preferred Phone 1
Preferred Phone 2
Allergies
Please list all known.
What is this camper allergic to?
- No known allergies
- Food
- Medicine
- The environment (insect stings, hay fever, etc.)
- Other
Please describe below what the camper is allergic to and the reaction seen.
Please be as precise as possible. For example: "If my daughter eats anything with nuts, she gets hives."
Diet Nutrition
Dietary Information
- This camper eats a regular diet.
- This camper eats a regular vegetarian diet.
- This camper has special food needs.
Special food needs
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
Restriction Information
- I have reviewed the program and activities of WeHaKee Camp for Girls and feel the camper can participate without restrictions.
- I have reviewed the program and activities of WeHaKee Camp for Girls and feel the camper can participate with the following restrictions or adaptations.
Restrictions or Limitations at Camp
Please be as precise as possible.
Medical Insurance Information
Is the camper covered by family medical insurance?
- Yes
- No
- Use the file upload field to send us a copy of your insurance card; copy both sides of the card so information is readable. Please fill out the rest of the medical information regarding your coverage information.
- Copy of Insurance
  Accepted file types: jpg, jpeg, png, pdf.
  The maximum file size to upload is 10MB. If your file is larger, please e-mail it to margaret@wehakeecampforgirls.com. Files that are accepted include: jpg, jpeg, png, and pdf.
- Insurance Company
- Policy Number
- Insurance Company Phone
- Subscriber
- Subscriber Number

Immunization History
Provide the month and year for each immunization. Starred (*) immunizations must be current. Copies of immunization forms from healthcare providers, or state or local government, are acceptable; please send into WeHaKee Camp for Girls.

Please provide all immunization dates.
Diphtheria, Tetanus, Pertussis (DTaP) or (TdaP) *
Dose 1 - Month/Year
Dose 2 - Month/Year
Dose 3 - Month/Year
Dose 4 - Month/Year
Dose 5 - Month/Year
Tetanus booster (dT) r (TdaP) *
Most Recent Dose - Month/Year
Mumps, measles, rubella (MMR) *
Dose 1 - Month/Year
Dose 2 - Month/Year
Most Recent Dose - Month/Year
Polio (IPV) *
Dose 1 - Month/Year
Dose 2 - Month/Year
Dose 3 - Month/Year
Dose 4 - Month/Year
Haemophilus influenza type B (HIB)
Dose 1 - Month/Year
Dose 2 - Month/Year
Dose 3 - Month/Year
Dose 4 - Month/Year
Pneumococcal (PCV)
Dose 1 - Month/Year
Dose 2 - Month/Year
Dose 3 - Month/Year
Dose 4 - Month/Year
Hepatitis B
Dose 1 - Month/Year
Dose 2 - Month/Year
Dose 3 - Month/Year
Hepatitis A
Dose 1 - Month/Year
Dose 2 - Month/Year
Varicella (Chicken Pox)
Has camper had chicken pox?
- Yes
- No
Date camper had chicken pox
MM
DD
YYYY
Dose 1 - Month/Year
Dose 2 - Month/Year
Meningococcal meningitis (MCV4)
Dose 1 - Month/Year
Tuberculosis (TB) Test
- Negative
- Positive
Date of TB Test
MM
DD
YYYY
Because our camp program has a potential for communicable diseases, we expect that program participants are appropriately immunized for, at minimum, the following diseases: tetanus, mumps, measles, rubella, polio, pertussis (whooping cough), meningitis, hepatitis B, varicella (chicken pox) and diphtheria. If this participant is not fully immunized per our expectation, please contact our Administrative Office prior to completing this Health History form.

Medication
“Medication” is any substance a person takes to maintain and/or improve their health—this includes vitamins & natural remedies. All medication (prescription and non-prescription, including vitamins and natural remedies) must be turned into the health director upon arrival at WeHaKee Camp for Girls.
Prescription Medication

ALL PRESCRIPTION MEDICATIONS MUST BE IN ORIGINAL PHARMACY CONTAINER WITH LABELS which shows the camper’s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
Camper Medication
- This camper will not take any daily medication while attending WeHaKee Camp for Girls
- This camper will take medication(s) while attending WeHaKee Camp for Girls.
- Name of Medication
- Date Started
  MM
  DD
  YYYY
- Reason for Taking It
- Time(s) to be Administered
  - Breakfast
  - Lunch
  - Dinner
  - Bedtime
  - Other time
- Other time
- Dosage
- How is it given?
Does the camper take a second medication?
- Yes
- No
- Name of Second Medication
- Date Started
  MM
  DD
  YYYY
- Reason for Taking It
- Time(s) to be Administered
  - Breakfast
  - Lunch
  - Dinner
  - Bedtime
  - Other time
- Other time
- Dosage
- How is it given?
Does the camper take a third medication?
- Yes
- No
- Name of Third Medication
- Date Started
  MM
  DD
  YYYY
- Reason for Taking It
- Time(s) to be Administered
  - Breakfast
  - Lunch
  - Dinner
  - Bedtime
  - Other time
- Other time
- Dosage
- How is it given?
Non-Prescription Medication - Including all over-the-counter medication.

Please do not send non-prescription medications with your child unless they are needed on a daily basis. If you send non-prescription medication with your child, IT MUST BE IN ITS ORIGINAL CONTAINER WITH LABELS. The below non-prescription medications may be stocked in the Health Center (BandAid) and are used on an as needed basis (PRN) to manage illness and injury. PLEASE SELECT THOSE THE CAMPER SHOULD NOT BE GIVEN.
Non-Prescription Medications
- Acetaminophen (Tylenol)
- Diphenhydramine antihistamine/allergy medicine (Benadryl)
- Sore throat spray
- Lice shampoo or cream (Nix or Elimite)
- Calamine lotion
- Stool softeners for constipation
- Ibuprofen (Advil, Motrin)
- Generic cough drops
- Antibiotic cream
- Aloe
General Health History - Has/Does the camper:
Check “Yes” or “No” for each statement. Explain “Yes” answers below.
Ever been hospitalized?
- Yes
- No
Ever had surgery?
- Yes
- No
Have a recurrent/chronic illness?
- Yes
- No
Lack the capability for self-management of illness/condition including asking for assistance when necessary?
- Yes
- No
Had an infectious disease in past 12 months?
- Yes
- No
Had an injury in past 12 months?
- Yes
- No
Had asthma/wheezing/shortness of breath?
- Yes
- No
Have diabetes?
- Yes
- No
Had seizures?
- Yes
- No
Had headaches?
- Yes
- No
Had a concussion(s)?
- Yes
- No
Wear glasses, contacts, protective eyewear?
- Yes
- No
Had fainting or dizziness?
- Yes
- No
Passed out/had chest pain during exercise?
- Yes
- No
Had mononucleosis (mono) during past 12 months?
- Yes
- No
Have problems with periods/menstruation?
- Yes
- No
Have problems with falling asleep/sleepwalking?
- Yes
- No
Ever had back/joint problems?
- Yes
- No
Have a history of bedwetting?
- Yes
- No
Have problems with diarrhea/constipation?
- Yes
- No
Have any skin problems?
- Yes
- No
Traveled outside of USA in the past 9 months?
- Yes
- No
Please explain ALL "Yes" answers in the space below, noting the number of each "Yes" response. Please include treatment plans or recommendations while at camp if applicable. For travel outside of the USA, please name countries visited and dates of travel.
Mental, Emotional and Social Health - Has/Does the camper:
Check “Yes” or “No” for each statement. Explain “Yes” answers below.
Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
- Yes
- No
Ever been treated for emotional or behavioral difficulties or an eating disorder?
- Yes
- No
Have a diagnosis of a psychological disorder such as depression, panic/anxiety/OCD?
- Yes
- No
During the past 12 months, seen a professional to address mental/emotional health concerns?
- Yes
- No
Had a significant life event that continues to affect the camper’s life?
- Yes
- No
(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others.)
Lack the ability to maintain appropriate personal hygiene abilities (bathe, brush teeth, etc. when appropriate)?
- Yes
- No
Lack the ability to interact effectively in a small group setting?
- Yes
- No
Please explain ALL "Yes" answers in the space below, noting the number of each "Yes" response. Please include treatment plans or recommendations while at camp if applicable. You may be contacted for additional information.
Health Care Providers
Name of primary care doctor(s)
Clinic/Location
Phone
Name of dentist(s)
Clinic/Location
Phone
Name of orthodontist(s)
Clinic/Location
Phone
Other health-care provider(s)
Clinic/Location
Phone
What Have We Forgotten to Ask?
Please provide any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program.
Parent/Guardian Authorization for Health Care
I confirm that I am the parent/legal guardian of the child listed on this Health History form and as such I have current legal custody of said child. 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.
Signature of Custodial Parent/Guardian
Date
MM
DD
YYYY
Relationship to Camper
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Summer Address

WeHaKee Camp for Girls
N8104 Barker Lake Road
Winter, Wisconsin 54896

Toll Free (USA): 1-800-582-2267

Phone (USA): 715-266-3263

Phone (International): 001-715-266-3263

Fax (USA): 715-266-2267

Fax (International): 001-715-266-2267

Winter Address

WeHaKee Camp for Girls
Administrative Office
715 28th Street South
La Crosse, Wisconsin 54601

Toll Free (USA): 1-800-582-2267

International Phone: 001-608-787-8304

Fax (USA): 608-787-8257

Fax (International): 001-608-787-8257

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