Medical Form

Phone Number

Yes, it's okay to send me text messages including confirmations, changes, updates, and/or promotions. Message frequency varies. Message and data rates may apply. View our terms of service & privacy policy.

Parent/Guardian #1

Relationship to Camper

Phone Number

Checkbox

The above Emergency Contact is approved to pick up and drop off this child.

Alternative Contact

Relationship to Camper

Phone Number

Checkbox

The above Emergency Contact is approved to pick up and drop off this child.

Is anyone else approved to pick up/drop off this child from camp?

If yes, please provide name, contact, and relationship here.

Describe any known allergies including reaction and treatment

List any dietary restrictions

List any medical conditions that staff should be informed of

Can this camper swim?

Beach Time*

This camper can attend beach activities.

Are there any other activity restrictions for this camper? If so, explain.

Is this camper medically insured

Company Phone Number

Policy Holder's Name

Please upload a copy of your Insurance Card

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Immunization History

Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form. Health-care form must include the following:

Diptheria, tetanus, pertussis (DTaP) or (TdaP) - Each Dose and date
Tetanus booster (dT) or (TdaP) - Most recent dose and date
Mumps, measles, rubella (MMR) - Dose and/or recent dose and date
Polio (IPV) - Doses and date
Haemophilus influenzae type B (HIB) - Doses and date
Pneumococcal (PCV) - Doses and date
Hepatitis B - Doses and date
Hepatitis A - Doses and date
Varicella (chicken pox) - If Had Chicken Pox list date
Meningococcal meningitis (MCV4) - Dose and date
Tuberculosis (TB) test - Date and if tested negative or positive

Have your medical provider fill out this Health Appraisal form

Attach form here

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Have you uploaded the immunization form from a healthcare provider?

List each dose and date:

Diptheria, tetanus, pertussis (DTaP) or (TdaP)

Tetanus booster (dT) or (TdaP) Most Recent Dose Month/Year

Mumps, measles, rubella (MMR)

Haemophilus influenzae type B (HIB)

Varicella (chicken pox) - If Had Chicken Pox list date

Meningococcal meningitis (MCV4)

Tuberculosis (TB) test - Date and if tested negative or positive

Not Fully Immunized

If your camper has NOT been fully immunized, please agree to the following statement: I understand and accept the risks to my child from not being fully immunized.

“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Medication MUST be in original pharmacy containers with labels that 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.

Will camper be taking medications while attending 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. Check any of the following that can be given to this camper.

General Health History

Check off each statement that applies.

Please explain "check marked" 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

Has the camper:

Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?
Ever been treated for emotional or behavioral difficulties or an eating disorder?
During the past 12 months, seen a professional to address mental/emotional health concerns?
Had a significant life event that continues to affect the camper’s life? (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)
None of the above

Please provide any additional information about items checked above.

Healthcare providers

Name of camper’s primary doctor(s):

Name of orthodontist(s):

What Have We Forgotten to Ask?

Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.

Parents Right to Know Notice

By checking the box below, I am acknowledging I have received a copy of the Parents Right to Know
Notice which states, “UNDER THE DELAWARE CODE, YOU ARE ENTITLED TO INSPECT THE
ACTIVE RECORD AND COMPLAINT FILES OF ANY LICENSED CHILD CARE FACILITY.” To review a
child care facility’s record located in Kent or Sussex County contact: the administrative
specialist, Office of Child Care Licensing, 821 Silver Lake Boulevard, Barratt Building, Suite 103,
Dover, DE 19904, phone (302) 739-5487.
You may also view substantiated complaints and compliance review histories by visiting the
Office of Child Care Licensing’s child care search at
https://education.delaware.gov/families/occl/child_care_search/.

I have read and agree to the terms above.

You will receive a Parent/Guardian Authorization for Health Care of a Minor agreement in your email upon submission. This form must be signed and submitted by the beginning of the first camp event.

Medical Form for Minors

Emergency Contacts

Restrictions

Insurance

Immunization History

Medications

General Health History

Mental, Emotional, and Social Health

Healthcare providers

What Have We Forgotten to Ask?

Almost done. Where should we send the confirmation?