Camper & Parent/Guardian Info Phone number * Additional phone number Email * Camper's additional address Emergency Contact
We will contact this person in the event that the parent/guardian listed above is not available.
Primary emergency contact's name * Relationship to camper * Phone * Additional emergency contact's name Relationship to camper Phone Medical Info Insurance company * Policy number * Group number * Physician's name * Physician's phone * Dentist's name * Dentist's phone * Date of camper's last tetanus shot MM 1 2 3 4 5 6 7 8 9 10 11 12 / DD 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / YYYY 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Medications Name of medication(s)/supplement(s), dosage, and directions for use: *
Please note: All medications your child takes, including over the counter, as needed, and prescription need to be brought in a sealed container or plastic bag with their name and directions for use. There must be enough medication (prescription and over the counter) to last the duration of camp. Unused medication will be returned at the end of camp. All medications are kept with medical staff on camp grounds. No camper is allowed to keep medication in their bunk.
Please list all allergies your child has including drug, food, insect stings, hay fever, asthma, animal dander, etc., and accompanying symptoms. * Does your child have difficulty sleeping or urinate in bed? If so, please explain how you handle this at home. * Is your child able to swim without flotation devices? * For girls: Has your child menstruated? Is there any additional information that would aid our camp staff in taking care of your child? Do they have any behavior, physical, emotional, or mental health challenges we should be aware of? Authorizations Please agree to the following statements and sign below. * This health history is correct to the best of my knowledge, and the camper named above has permission to engage in all camp activities as noted. I certify that I am the camper's legal parent or guardian, and give permission for said camper to use camp transportation to participate in offsite activities. I give consent for Camp Be'chol Lashon medical staff to dispense my child's prescription medications to him/her, as well as over-the-counter medications, sunscreen, and insect repellent. I acknowledge and understand there are inherent risks associated with many camp activities. I will assume the risk associated therewith, whether known or unknown to me at this time. I recognize that my attendance at Camp Be'chol Lashon is a privilege and as a consideration for this privilege, I release Camp Be'chol Lashon, including its employees, agents, and trustees, from responsibility for my accidental physical injury, including death or illness, and loss of personal property while at camp or during Camp Be'chol Lashon sponsored travel to and from camp. This release is also intended to include all claims made by the family, estate, heirs, personal representative or assigns. I grant permission for my child to participate in all special trips off the camp property with the proper staff supervision. I authorize Camp Be'chol Lashon staff to seek any medical care necessary for my child, including basic first aid on camp grounds or care at the nearest hospital, in case of an emergency. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment; to maintain and/or release any medical records necessary for insurance purposes as outlined under HIPAA regulations; and to provide or arrange necessary related transportation for me or my child. In an emergency, I hereby give permission and authorize the physician selected by Camp Be'chol Lashon to secure and administer emergency medical treatment, including hospitalization and any other emergency medical procedures which may be needed for the person named herein. I authorize the physician or dentist to call in any necessary consultants in his/her discretion. It is understood that this consent is given in advance of any specific diagnosis or treatment being required, and is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise their best judgement as to the requirements of such diagnosis or medical, dental, or surgical treatment. I hereby grant to Camp Be'chol Lashon the right to use, reproduce, and/or distribute photographs, films, videotapes, and sound recordings of my child, without compensation or approval rights, for use in material created for the purposes of promoting the activities of Camp Be'chol Lashon.