WCYC confidential camper health form

To be completed and signed by Parent or Guardian

(Please print)

                         Date of

Camper Name_________________________________Birth  ____/____/____  Age___ M____F____

Parents' Names _________________________________________________________________

Home/cell Phones   (___)______________

                            (___)______________

Home Address______________________________________

city________________________    state_____    zip ____________

                                                           

Work Phones  (___)______________                           

                     (___)______________

                  

Family Doctor ______________________________________

Doctor's Phone(___)______________

Office Address______________________________________                                                                   city ________________________  state_____  zip  _______________

Other Emergency Contact and Telephone Numbers   

Name____________________________Home Phone(___)_____________Work Phone(___)______

Wisconsin Christian Youth Camp carries insurance for each camper.  In the event a camper requires treatment for a pre-existing problem or intentional self-inflicted injury, the bill will be sent to parents as these are not covered by WCYC.

WCYC requires that ALL medications be surrendered to the camp nurse upon arrival at camp.  The camp nurse will store the medications and dispense them according to Physician's directions on original labeled containers given to the nurse.

All tick bites while at camp must be brought to the nurse so diagnosis can be made for possible Lymes infection.

Date of last Tetanus Booster___/___/___ Known Allergies & Reactions________________________

Has camper been exposed to any communicable disease (strep, measles, etc. in past three weeks)?

List medications, dosages, conditions and serious injuries or operations and whether or not follow up will be necessary while at camp. (use back if necessary)  Please provide a photocopy of your insurance card.

________________________________________________________________________________

Is camper permitted to take over-the-counter preparations at the nurse's discretion?  Yes___   No___

Other information that will be helpful to the camp nurse while your child is at camp._______________

________________________________________________________________________________

I hereby authorize Wisconsin Christian Youth Camp to seek medical treatment, shots, or

X-Rays for (camper name) ___________________________in an emergency situation.  WCYC

has this authorization (dates while attending camp) from____/____/____to____/____/____.

______________________________________________  DATE ____/____/____

SIGNATURE OF PARENT OR GUARDIAN