Class 1 Personal Health History

(from  Registration form 28-102J)

Identification: To be filled out by parent or guardian. Please print in ink.

Name_________________________________________________________________ Date of birth_________________ Age_______

Name of parent or guardian__________________________________________________Telephone___________________________

Home address ____________________________________________City____________________ State ____   Zip code___________

Check all items that apply, past or present, to your health history. Explain any  “Yes" answers.

Allergies: Food, medicines, insects, plants:    Yes (  ),  No (  )

   Explain: ____________________________________________­­­­­_______________________________________________________

 

General Information:                  Yes  No                                                      Yes  No                                                      Yes  No

ADHD*                                            (  )   (  )           Convulsions/seizures    (  )   (  )           Hemophilia                        (  )   (  )

Asthma                                          (  )   (  )           Diabetes                            (  )   (  )           High blood pressure      (  )   (  )

Cancer/leukemia                          (  )   (  )           Heart trouble                     (  )   (  )           Kidney disease                 (  )   (  )  

                                                       

*ADHD is Attention Deficit Hyperactivity Disorder

                             

List any medications to be taken at camp: _____________________________________________________________________

List any physical or behavioral conditions that may affect or limit full participation in swimming, backpacking, hiking long distances, or playing strenuous physical games: _______________________________________________________________________________

List equipment needed such as wheelchair, braces, glasses, contact lenses, etc.: ___________________________________________

 

Immunizations (give date of last inoculation):

Tetanus toxoid ________________   Pertussis __________________   Mumps ___________________ Polio ____________________

Diphtheria ____________________Measles_____________________ Rubella___________________     _______________________

Name of personal physician ____________________________________________________________ Telephone________________

Personal health/accident insurance carrier. ________________________________________________ Policy No. ________________

 

Parent Authorization:

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by me. In the event of illness or accident in the course of such activity, I request that measures be instituted without delay as the judgment of medical personnel dictates.

 

Signature   __________________________________________________________________________   Date __________________

Parent  or guardian