Soft Ball Consulting

YOUTH CAMP HEALTH HISTORY CAMPER

Child’s Name:

Current residence:

EMERGENCY CONTACT INFORMATION

Emergency Contact (Parent or Legal Guardian):

Phone:

2nd Emergency Contact (Other than Parent Above):

Phone:

Primary Care Physician or other provider of medical care:

Phone:

HEALTH INFORMATION:

Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?

Yes

Explain

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?

Yes

Explain

IMMUNIZATION INFORMATION:

Must list current residence above.

For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?

Yes

List

For campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896.

Health History

YOUTH CAMP HEALTH HISTORY CAMPER

EMERGENCY CONTACT INFORMATION

HEALTH INFORMATION:

IMMUNIZATION INFORMATION: