1973 N. 35th Road, Ottawa, IL 61350
Camper Health History
To Parent(s)/Guardian(s): Please follow the instructions below. Add additional information if needed.
Please complete this form. This is health history information and does not require a doctor's signature. This form must be completed and received prior to arrival at camp.
Page 2 Health History Form
If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized.
“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/container's. Many states require original pharmacy containers with labels which show 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.
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Check those that the camper should not be given.
General Health History
Check “Yes” or “No" for each statement. Explain “Yes” answers below.
Please explain "Yes" answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. (E.g. #21 - don't put near a door.)
Check “Yes” or “No” for each statement.
This health history is correct and accurately reflects the health status of the camper to whom it pertains. 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 heath 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 that 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, the camp has 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.
Please provide in the space below 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. Attach additional information if needed.
Thank you for filling out the Camper Health History Form. We appreciate your cooperation in helping us to provide your child(ren) with the best possible experience at Camp Tuckabatchee!
See you at camp!