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Camp Wamp Health Form

This form is to be completed for each camper who will be at Camp Wamp during the Summer 2023 camp season.

Parents of Campers: Please give us as much information as possible about your camper and their health to ensure a successful experience at Camp Wamp.

Parent / Legal Guardian Contact Information:





Camper Information:



COVID-19
The safety and well-being of our campers, their families, our volunteers, and our staff are of the utmost importance to us at Camp Wamp. We are taking all possible and appropriate measures to ensure everyone has a safe experience at Camp Wamp this summer. 

As we continue to monitor developments regarding COVID-19, we are reviewing updates from the CDC, the ACA, and  Department of Public Health daily. We understand the concern surrounding the possible impacts of our programs. We are paying close attention to local guidance and are following all preventive measures to protect the vulnerable population we serve.



Allergies:



Diet and Nutrition:



Restrictions:



Medical Insurance Information:

Please make a photocopy of the front and back of your camper's health insurance and Covid-19 card and bring it, along with the completed Physician Signature form, to camp with your camper on Check-In Day.





Immunization History:

Provide the month and year for each immunization. Starred (*) immunizations must be current. Copies of immunization forms from health care providers or state or local government are acceptable; please attach to this form.









Varicella (chicken pox)



Tuberculosis (TB)






Medication:


"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins and natural remedies. Please send all medications in their original pharmacy containers with labels which show the camper's name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.

General Health History: 

Check "Yes" or "No" for each statement. Explain "Yes" answers below.

Has/does the camper:






















Mental, Emotional, and Social Health:

Check "Yes" or "No" for each statement.

Has the camper:





Health-Care Providers:







What Have We Forgotten to Ask?


Permission to Treat Authorization

I hereby give permission to the medical personnel to provide routine health care; to administer prescribed medications; and to administer emergency treatment for me/my child, including, but not limited to X-rays, routine tests and treatment and/or hospitalization; and to provide or arrange necessary related transportation for me/my child. I also agree to the release of any records necessary for treatment, referral, billing or insurance purposes.

If the person named herein is a minor, it is my intention that representatives of the camp be considered "personal representatives" for the purpose of disclosing health information that is protected under the Health Insurance Portability and Accountability Act of 1996. I also agree to the disclosure to camp representatives of protected health information of the person named herein in order to provide information related to the person's ability to participate in camp activities; and if the person named herein is a minor, to to provide information to the camp representatives to keep me informed of my child's health situation.

In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the named person. This completed form may be photocopied for trips out of camp.

Contact Information