Camper Health Form
Camper Name _____________________________________ Date of Birth ________________
Healthcare recommendations by licensed healthcare provider for ____________________________________
Name of camper
This examination report page is to be completed and signed by the participant's primary care provider. It must be based on an
exam completed during the school year prior to the beginning of camp.
Date of exam _____________________
Blood pressure __________ Weight _________ Height _________
In my opinion, the applicant q is q is not able to participate in an active camp program.
The camper is under the care of a physician for the following condition(s) _______________________________________________
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Active treatment at the time of this report includes _____________________________________________________________________
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Recommendations and restrictions for camp program
Treatment to be continued at camp _______________________________________________________________________________
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Medications to be administered at camp (name, dosage, frequency) _____________________________________________________
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Any medically-prescribed meal plan or dietary restrictions ____________________________________________________________
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Known allergies _____________________________________________________________________________________________
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(Note: Allergy desensitization treatments will only be permitted with a doctor’s written order)
Description of any limitations or restrictions of camp activities ________________________________________________________
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Additional information for the camp health care staff ________________________________________________________________
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• Please include a copy of immunization record with this form
Signature of licensed healthcare provider ____________________________________________ Date _____________________
Printed Name _______________________________________________________ Phone ______________________________
Address ________________________________________________________________________________________________
Street address City State Zip Code