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Health history short form 3nights_or_less 2013

Health History Form for 2013
Monadnock Bible Conference
Short-Term Campers (3 Nights or Less)
Camper Name: ______________________________________________________________ Date of Birth: _____________________________________ □ Male □ Female ______________________
Monadnock Bible Conference will call when there is a question about your child’s health and/or ______________________
in an emergency. Provide contact information for a custodial parent who will be available via phone while your child is attending our program: ______________________
Parent/Guardian: ______________________________________________________________ Preferred Phone #: (________)___________________________________________________ ______________________
Alternate Phone #: (________)___________________________________________________ Questions?
Call Sue Williams at
Parent/Guardian Address: _______________________________________________________ 603-532-8321
____________________________________________________________________________ About health care for short-term camper stays: • At minimum, a staff member with EMT, First Aid, and CPR qualifications (usually an R.N.) is at camp when campers are present • Campers should arrive ready to participate in the program. • You must let the camp know of any limitations concerning your child: ____________________________________________ ____________________________________________________________________________________________________ “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Monadnock Bible Conference and NH State Law requires original pharmacy containers with labels, which show the camper’s
name and how the medication should be given. Please provide enough of each medication to last the entire time this
camper will be at camp.


All medication is to be turned in to and reviewed with the camp’s healthcare professional upon arrival to camp. The

group leader or parent should review the expected schedule and doses with the healthcare professional at check-in.
The camp’s healthcare professional will distribute medications according to this document as reviewed at check-in.

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. Cross out those this camper should not be given.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Epinephrine (Epi-pen for severe allegoric reactions) Lice shampoo or cream (Nix, Elimite, or mayonnaise) 1. Date (month & year) of this child’s most recent tetanus immunization ____________________________________
a. If not immunized, would you allow camp to send this child to the ER for immunization if needed? . . . □ Yes □ No 2. Is this child allergic to any food or medication? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ Yes □ No
If YES, name the item and indicate the reaction: ______________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Signature of Parent/Guardian: _____________________________________________________ Date: _________________
This  is  side  1  –  Please  be  sure  to  fil  out  and  sign  BOTH  sides  of  this  form  
3. Does your child use/carry an epi-pen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . □ Yes □ No
a. Does this child have medical concerns such as asthma, diabetes, seizures, etc.? . . . . . . . . . . . . . . . □ Yes □ No b. If Yes, what: _______________________________________________________________________________ If YES, what triggers your child’s medical problem (asthma, diabetes, seizures, etc.)? _______________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
4. List all medications including OTC medications/inhalers this child takes on a routine basis:
□ This camper takes no routine medication. □ This camper will be expected to take the following routine medication (including dosage) while at camp: a. Med/dose: ____________________ Reason for taking this: ______________________________ Time/Schedule _______ b. Med/dose: ____________________ Reason for taking this: ______________________________ Time/Schedule _______ c. Med/dose: ____________________ Reason for taking this: ______________________________ Time/Schedule _______
5. What else should we know about your child? Please write additional information about your child’s health that may impact
your child’s participation in our program: _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________
6. Insurance information:
Subscriber's Full Name (Parent/Guardian/Self): ____________________________________ Date of Birth ____/____/_______ Name Insurance Company___________________________________ Insurance ID# ________________________________ Insurance Phone # ( _________ ) ________________ ____________________ If possible, please attach a copy of the insurance card.

Photo/Video/Audio Release Statement
In registering my child for any event at Monadnock Bible Conference, I agree to the use by Monadnock Bible Conference and any
of it’s ministries of my child's name, image, and/or video for art and/or promotional materials.
Although pictures, audio, and video taken during camp may include your child, there is no guarantee that he/she will be featured
in any of the aforementioned materials. These materials may be used online, in print, and may be distributed via the Internet,
mail, public media, or over the air.

Parent/Guardian Authorization
This information is correct and the child described has permission to participate in all camp activities except as noted on this
form. I understand the camp has limited healthcare on site and the staff will call the indicated parent/guardian (a) in an
emergency, (b) if questions about my child’s health may arise, and/or (c) when my child is unable to continue because of injury or
illness. I understand all medications including OTC meds are to be turned in to the camp medical staff and reviewed with the
check-in medical professional. I acknowledge the camp’s healthcare professional will handle medication as described and the
information on this form will be shared with staff on a need-to-know basis.
Signature of Parent/Guardian: _____________________________________________________ Date: _________________
This  is  side  2  –  Please  be  sure  to  fil  out  and  sign  BOTH  sides  of  this  form  

Source: http://pascackbible.org/wp-content/uploads/2012/09/ShortMedForm-2013.pdf

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