HEALTH HISTORY/EMERGENCY CONTACT INFORMATION

Required for Camp Cispus Attendance (green form)

Student: _____________________________________School________________________Teacher__________________

 Home Address___________________________Home Phone_________________________Cell_____________________

 Parent:__________________________________Work Phone____________________Health Insurance______________

Emergency Contacts: Name and phone number of two people to call in case of illness or injury (when you cannot be reached) who could get a message to your or assume responsibility for your child if needed. (Relative, friend or neighbor)

Name_____________________________________________________Numbers_______________________________________________________  

Name_____________________________________________________Numbers_______________________________________________________

MEDICAL HISTORY

      (Check all that apply to your child)

 Allergies to:  Foods______________Drugs_____________Plants___________Bee Sting________(Sever with excessive swelling/difficulty breathing)

 Is emergency treatment needed?  Yes ______No______ If yes, what treatment?  Epi Pen_____Benadryl_____911_____other_________________

 Asthma: yes____No____ Mild_____Moderate_____Severe______   Inhaler required?    Yes      No            *Need’s to carry:        Yes        No

 Seizure Disorder__________Diabetic___________Anxiety________ADD/ADHD__________Heart Disorder________Sleep-Walking/Talking_______

 Poor sleeping habits________Home Sick_________Bed Wetting________ Vegetarian_________Gluten Free Diet_________

 Limited Activity (Explain)__________________________________________________________________________________________________

 Additional information_____________________________________________________________________________________________________

 ________________________________________________________________________________________________________________________

 ________________________________________________________________________________________________________________________

(Use the back of this form if needed for any additional information that may be helpful)

MEDICATIONS

List  ALL medications that you will be sending to camp for your child. Include any treatment medicine listed above, prescription and over-the-counter medicines.    ANY and  ALL medicines require a doctor signature

______________________________________________            _______________________________________________

______________________________________________            _______________________________________________

_______________________________________________          _______________________________________________

PLEASE NOTE: Washington State Law requires both doctor and parent authorization/signature for ANY and ALL medicines to be given

**All medications need to be sent from your home supply and in the original container’s

*You need only send a 3 -day supply. “Due 2 weeks prior to camp”   (Conference week Mar 26-Mar 30, 2018)

Parent/Guardian Signature_____________________________________________Date_________________________