Camper/Staff Name: ________________________________________________________________________________ Birth Date ____________ Age on arrival at camp: ________ To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed.
Return this form attached to camp application to
Complete pages 1, 2 and 3 of this form (FORM 2011) and make a copy for your file.
your local Nazarene Church camp coordinator
Return the original, signed FORM 2011 to Local Camp Coordinator with the camp application.
Copy both sides of your insurance card and attached to this Health History Form 2011.
Camper/Staff Home Address: __________________________________________________________________________________________________________________ Parent/guardian with legal custody to be contacted in case of illness or injury: Name: ____________________________ to Camper/Staff: ________________Preferred Phones: (______) _______________ (______)_________________ Home Address: ____________________________________________________________________________________________________________________________________________________ (If different from above) Street Address Second parent/guardian or other emergency contact: Name: ____________________________ to Camper/Staff: ________________Preferred Phones: (______) ________________ (______)_________________ Additional contact in event parent(s)/guardian(s) can not be reached: Name(s): __________________________ to Camper/Staff: ________________ Preferred Phones: (______) ________________ (______)_________________ Allergies:
 This camper/staff is allergic to:  Food  Medicine  The environment (insect stings, hay fever, etc.)  Other (Please describe below what the camper is allergic to and the reaction seen.)
Diet, Nutrition:  This camper/staff eats a regular diet.  This camper/staff eats a regular vegetarian diet.
 This camper/staff has special food needs. (Please describe below.)
Restrictions:  I have reviewed the program and activities of the camp/staff and feel the camper can participate without restrictions.
 I have reviewed the program and activities of the camp and feel the camper/staff can participate with the following restrictions or adaptations. (Please describe below.)
Medical Insurance Information:
This camper or staff is covered by family medical/hospital insurance A copy of your insurance card must be attached to this Health Form.
Be sure to copy both sides of the card so information is readable.
Parent/Guardian Authorization for Health Care:
This health history is correct and accurately reflects the health status of the camper/staff to whom it pertains. The person described has permission to participate
in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests,
and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my
permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on
this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a
copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
Parent/Guardian or Staff Adult __________________________________________________Date: Camper/Staff Name: ____________________________________________ 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. Statements such as “UP TO DATE” or “COMPLETE” will not be accepted.
Admission to camp may be denied on the basis (completeness) of this information.
Diptheria, tetanus, pertussis  (DTaP) or (TdaP) (chicken pox) Date: Meningococcal meningitis (MCV4) IF a Tuberculosis (TB) test has been taken  Date:
If your camper has NOT been fully immunized, a responsible adult must sign the following statement

I understand and accept the risks to my child from not being fully immunized.
Parent/Guardian or Staff Adult ___________________________________________________ Date:
 This camper or staff will not take any daily medications while attending camp. This camper or staff will take the following daily prescription/prescribed medication(s) while at camp: "Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. ILNC requires all prescribed medication
be delivered in original pharmacy containers with labels which show the camper’s name and how the prescribed medication should be given. Provide enough
of each medication to last the entire time the camper will be at camp. Non-prescribed medication, nutrients or supplements will not be admitted with camper.

 Breakfast  Lunch  Dinner  Bedtime  Other time:___________  Breakfast  Lunch  Dinner  Bedtime  Other time:___________  Breakfast  Lunch  Dinner  Bedtime  Other time:___________ The following non-prescription medications may be stocked in the camp Health Center and are dispensed on an as needed basis to manage common illnesses and Injuries as directed by Standing Orders signed by ILNC’s supervising physician. Cross out those the camper should not be given.
Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Camper/Staff Name: ___________________________________________ General Health History: Check "Yes" or "No" for each statement. Explain “Yes” answers below.
1. Ever been hospitalized? ………………………….  Yes  No 11. Had fainting, dizziness or headaches? .  Yes  No
2. Ever had surgery? . ………….  Yes  No 12. Passed out/had chest pain during exercise? ….…………….  Yes  No
3. Have recurrent/chronic illnesses? .……….…  Yes  No 13. Had mononucleosis ("mono") during the past 12 months?.  Yes  No
4. Had a recent infectious disease? . ………….  Yes  No 14. If female, have problems with periods/menstruation?.…….  Yes  No
5. Had a recent injury? . ………….  Yes  No 15. Have problems with falling asleep/sleepwalking? .
6. Had asthma/wheezing/shortness of breath?.  Yes  No 16. Ever had back/joint problems?…….……….…………….  Yes  No
7. Have diabetes? . ………….  Yes  No 17. Have a history of bedwetting?………………….…………….  Yes  No
8. Had seizures? .  Yes  No 18. Have problems with diarrhea/constipation?……………….  Yes  No
9. Had headaches? ………………………………….  Yes  No 19. Have any skin problems?…………………….  Yes  No
10. Wear glasses, contacts, or protective eyewear?  Yes  No 20. Traveled outside the country in the past 9 months?.  Yes  No
Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel.

Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ……………………….  Yes  No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?…….  Yes  No 3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….………………………………….  Yes  No 4. Had a significant life event that continues to affect the camper’s life?.  Yes  No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)
Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.
Health-Care Providers:
Name of camper/staff primary doctor(s): __________________________________________________ Phone: (________) _______________________ Name of dentist(s):___________________________________________________________________ Phone: (________) _______________________ Name of orthodontist(s):_______________________________________________________________ Phone: (________) _______________________
What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s or staff’s health that you think
important or that may affect the camper’s (staff’s) ability to fully participate in the camp program. Attach additional information if needed.
Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records.
Camper/Staff Name: ___________________________________________ Individual Health Record (For Camp Use Only)
Initial Screening
Date/Time: ____________________
Initials: ____________
Screening has been conducted according to camp protocol and significant findings noted as follows:
A. Any signs/symptoms of illness or injury upon arrival?.  No  Yes as noted below B. History of exposure to communicable disease?.  No  Yes as noted below C. Additions or corrections to information on this health history?.  No  Yes as noted below D. Medication given to health-care staff?.  No  Yes as noted below E. Any signs/symptoms of head lice?.  No  Yes as noted below
Provider notes: (date/time/initial all entries) _____________________________________________________________________________
____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Exit Note: Check one of the following:
 Left camp this day with no reported illness or injury symptoms.  Left camp this day with the following problem/concern: ______________________________________________________________________________________________________________ This person was told about the problem and instructed about follow-up as noted above: __________________________________________ Date/Time: ______________________ Initials: ___________



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