Medical Information Form

A.  I certify that (camper's name)____________________________________ is in good physical health and carries not illness that would endanger the health of other campers or staff.

B.  Camper's Age:_____  Birthday:__________ Date of last tetanus or booster:__________

C.  Emergency phone numbers:  Day:_______________ Night:______________ Cell:______________

D.  List any known allergies (plant, animal, bee, medicine, etc.:__________________________________________

E.  List any medications the camper will bring to camp:________________________________________________

F.  I acknowledge that accident Insurance only is provided by Southern Illinois Christian Service Camp, which will go into effect after our family insurance has been charged or if I have no insurance.  If my child becomes ill and is subsequently hospitalized, or family insurance or me personally will be responsible.
G.  I  here by release the management, staff, volunteer workers, or officers of Southern Illinois Christian Service Camp of any responsibility for accidents unless guilty of negligence.
H.  In case of emergency, I hereby give permission to the physician selected by the camp management to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child named above on this form.  I understand, however, that every effort will be made to contact me incase of any such emergency before any such treatment is administered.
I.  I give permission for camp photos or videos that include my child to be used for camp promotion.

Signature of Parent or Guardian_________________________________________ Date:___________________

Camper's Name:_____________________________________

To the best of your knowledge has this camper been exposed to or diagnosed with head lice during the past week?

No:__________

Yes:__________  (Please see the First Aid Supervisor at the medical table before taking your child to the cabin.)

Signed:______________________________________    Date:_____________

Relationship:_________________________________________

I give the First Aid Supervisor permission to share medical information concerning
(camper's name)_________________________________ with those she believes need to know for the welfare of the camper.

Example:  Camper has a bee sting allergy.  The recreation personnel, cabin parents, etc. should know this in case the camper is stung.  They will know this is an emergence and seek help immediately.

I also give the First Aid Supervisor permission to give my child over the counter medication (Tylenol, Ibuprofen, Tums, tec.) unless I tell her otherwise.

Signed:__________________________________  Date: ___________________

Relationship: _____________________________

(Office Use:  Cabin_______________   Bunk _______________   Group ______________)