Name(Required) First Last Age(Required) Gender(Required) Male Female Health/accident insurance company(Required) IF FAMILY HAS NO MEDICAL INSURANCE, STATE “NONE.” Policy. No(Required) Parent/Camper Questions, Request and CommentsAre you now, or have you ever, been treated for any of the following(Required) Asthma Date of last attack: Diabetes Date of last HbA1c: Hypertension (high blood pressure) Heart disease (e.g. CHF, CAD, MI) Stroke/TIA Lung/respiratory disease Ear/sinus problems Muscular/skeletal condition Psychiatric/psychological and emotional difficulties Behavioral disorders (e.g. ADD, ADHD, Asperger syndrome, autism) Bleeding disorders Fainting spells Seizures Date of last seizure: Sleep disorders (e.g. sleep apnea) Abdominal/digestive problems Surgery Serious injury None of the above Immunizations received(Required) Tetanus Pertussis Diphtheria Measles Mumps Rubella Polio Chicken pox Hepatitis A Hepatitis B Influenza Please select all that apply(Required) Allergies Medications None AllergiesMedicationsPlease confirm(Required) Be sure to bring medications, EpiPens, and inhalers in sufficient quantities and in the original containers. Make sure they are NOT expired. You SHOULD NOT STOP taking any maintenance medication.Parent or Guardian Signature(Required)
