Camper Health History Form

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Session Attending(Required)

Camper Legal Name(Required)

First, Middle, and Last

Sex Assigned At Birth(Required)

Female

Male

Camper Birthdate(Required)

Month

Day

Year

Age(Required)

To Parent(s)/Guardian(s):

Please submit the completed form by May 1st to WeHaKee Camp for Girls Administrative Office. Please follow the instructions below.

Only ONE CAMPER per form!
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).
Submit this form by May 1st
If your child has significant health issues that will directly impact their 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

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

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

Medical Insurance Information

Is the camper covered by family medical insurance?

Yes

You are required to submit a copy of your health insurance card (copy both sides of the card so information is readable!). Use the file upload field to send us a copy of your insurance card.

Please fill out the rest of the medical information regarding your coverage information.

Copy of Insurance

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 7 MB.

The maximum file size to upload is 7MB. 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

This camper is currently vaccinated in accordance with the American Academy of Pediatrics’ most recent Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger (including the following vaccinations for diphtheria, tetanus, pertussis, mumps, measles, rubella, COVID-19, PCV, Hepatitis B and A, Varicella/chicken pox, meningococcal meningitis).(Required)

Yes

No*

*If NO to any of these vaccinations, please contact our Administrative Office as soon as possible.

Please provide official documentation of your child’s immunization history. This documentation can be acquired from your family healthcare provider of from your local or state government. This form is not complete and your child may not be admitted to camp without this official documentation.

Because our camp community has the potential for the presence of communicable diseases, all program participants are REQUIRED to be vaccinated in accordance with the American Academy of Pediatrics’ most recent Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger (https://tinyurl.com/y7bkysdf). Only medical exemptions to our immunization requirement will be considered.

Official written documentation signed by an appropriately licensed medical professional is required for exemption consideration.

Copy Of Official Documentation Of Child’s Immunization History

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 7 MB.

The maximum file size to upload is 7MB. If your file is larger, please e-mail it to margaret@wehakeecampforgirls.com. Files that are accepted include: jpg, jpeg, png, and pdf.

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."

Medication

“Medication” is any substance a person takes to maintain and/or improve their health - this includes vitamins, supplements, and homeopathics. All medication (prescription and non-prescription, including vitamins, supplements, and homeopathics) 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

Month

Day

Year

Reason for Taking It

Time(s) to be Administered

Breakfast

Lunch

Dinner

Bedtime

Other time

Dosage

How is it given?

Does the camper take a second medication?

Yes

Name of Second Medication

Date Started

Month

Day

Year

Reason for Taking It

Time(s) to be Administered

Breakfast

Lunch

Dinner

Bedtime

Other time

Dosage

How is it given?

Does the camper take a third medication?

Yes

Name of Third Medication

Date Started

Month

Day

Year

Reason for Taking It

Time(s) to be Administered

Breakfast

Lunch

Dinner

Bedtime

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 ALL LABELS ATTACHED.

Health Care Providers

Name of primary care doctor(s)

Clinic/Location

Phone

Other health-care provider(s)

Clinic/Location

Phone

Diet Nutrition

Dietary Information

This camper eats a regular diet.

This camper eats a regular vegetarian diet.

This camper eats a Vegan 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 I confirm that the camper can participate without restrictions.

I have reviewed the program and activities of WeHaKee Camp for Girls and I confirm that the camper can participate with the following restrictions or adaptations.

Restrictions or Limitations at Camp

Please be as precise as possible.

General Health History - Has/Does the camper:

Check “Yes” or “No” for each statement. Explain “Yes” answers below.

1. Ever been hospitalized?

Yes

2. Ever had surgery?

Yes

3. Have a recurrent/chronic illness?

Yes

4. Had an infectious disease in past 12 months?

Yes

5. Had an injury in past 12 months?

Yes

6. Had asthma/wheezing/shortness of breath?

Yes

7. Have diabetes?

Yes

8. Had seizures?

Yes

9. Had headaches?

Yes

10. Had a concussion(s)?

Yes

11. Wear glasses, contacts, protective eyewear?

Yes

12. Had fainting or dizziness?

Yes

13. Passed out/had chest pain during exercise?

Yes

14. Had mononucleosis (mono) during past 12 months?

Yes

15. Have problems with periods/menstruation?

Yes

16. Have problems with falling asleep/sleepwalking?

Yes

17. Ever had back/joint problems?

Yes

18. Have a history of bedwetting?

Yes

19. Have problems with diarrhea/constipation?

Yes

20. Have any skin problems?

Yes

21. Traveled outside of USA in the past 9 months?

Yes

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. Also include a description of the camper's capability for self-management of the illness/condition including asking for assistance when necessary. 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.

1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?

Yes

2. Ever been treated for emotional or behavioral difficulties?

Yes

3. Currently have an eating disorder or been treated for one in the past?

Yes

4. Experienced excessive anxiety or panic attacks?

Yes

5. Experienced symptoms consistent with depression, panic/anxiety/OCD?

Yes

6. Have a diagnosis of a psychological disorder such as depression, panic/anxiety/OCD?

Yes

7. Exhibit challenges in engaging or interacting with others?

Yes

8. Exhibit challenges in successfully managing their ability to live in community with others?

Yes

9. During the past 12 months, seen a professional to address mental/emotional health concerns?

Yes

10. Had a significant life event that continues to affect the camper’s life?

Yes

(History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others.)

11. LACK personal appropriate hygiene abilities (bathe, brush teeth, etc. when appropriate)?

Yes

12. LACK the ability to interact effectively in a small group setting?

Yes

13. Had/Have any significant issues during their lifetime that has resulted in them experiencing any mental, emotional, social or other distress?

Yes

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.

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

As needed, we will call this child's health-care provider directly to clarify treatment plans and other related care. Check a box below if you prefer we DO or Do NOT make direct contact with the child's health-care provider.(Required)

Please DO contact the health provider prior to contacting us (parent/guardian).

Please DO NOT contact the health provider prior to contacting us (parent/guardian).

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 complete and thorough and accurately reflects the health status of the camper to whom it pertains. I attest that all of my child’s immunizations are up to date in accordance with the American Academy of Pediatrics’ most recent Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger. 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. In the event that my child is hospitalized for an extended period (more than 1 night), I understand that I am responsible for making immediate arrangements to travel to their hospital location to provide supervision, personal support, transportation, etc. I understand the information on this form may 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(Required)

Date(Required)

Month

Day

Year

Relationship to Camper(Required)

CAPTCHA

This field is for validation purposes and should be left unchanged.

Camper Health History Form

To Parent(s)/Guardian(s):

Camper Information

Parent/Guardian Information

Medical Insurance Information

Immunization History

Allergies

Medication

Prescription Medication

Non-Prescription Medication - Including all over-the-counter medication.

Health Care Providers

Diet Nutrition

Restrictions

General Health History - Has/Does the camper:

Mental, Emotional and Social Health - Has/Does the camper:

What Have We Forgotten to Ask?

Parent/Guardian Authorization for Health Care

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