Camper Health History Form

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 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 her 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.