logo 20221973 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.

Camper Information
Parent/Guardian with Legal Custody

 To be contacted in case of emergency.

Second Parent/Guardian

Second Parent/Guardian or Other Emergency Contact

Additional Contact

In the event the parent(s)/guardian(s) cannot be reached.

Health & Nutrition

Medical Insurance Information

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.


 Executive Director ~ Rj Swett
Camp Director ~ Elizabeth Swett
Fundraising & Events Coordinator ~ Ken Hicks

Phone: (815)-433-2984
1973 N 35th Rd
Ottawa, IL 61350

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Copyright © Camp Tuckabatchee

In loving memory of Kelly Bunnell

In Memory of Kelly Bunnell 8/6/1960 to 9/10/2021

8/6/1960 to 9/10/2021