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Cowen health form 2012.pub
Camp Attending _______________________________________________________________________ Year _________________________
WEST VIRGINIA BAPTIST CAMP AT COWEN
PERMISSION FOR EMERGENCY TREATMENT & HEALTH HISTORY
Please fill out this form as completely as possible. Campers are not singled out, made to feel embarrassed or treated differently
because of information gathered from the health form. Rather, the more we know ahead of time, the easier it is to help your child
have a successful experience at camp. Thank you! Please mail or bring this form to camp on your day of arrival.
Every camper needs a completed health form to participate in any Cowen summer camp programs.
SECTION I – BASIC CONTACT INFORMATION
Name _______________________________________________________________ Birthdate ___________________ Age at Camp __________________
Home Address ____________________________________________________________________________________________________________________
Social Security Number of participant ______________________________________________________________ Gender: M F Camper Lives With: Mother & Father Mother Father Grandparent Other: ______________________________________________ Custodial Parent/Guardian _______________________________________________________________________ Phone __________________________ Home Address ____________________________________________________________________________________________________________________ (If different from above)
Business Address _______________________________________________________________________________ Phone __________________________
If not available in an emergency, notify ______________________________________________________________________________________________ Relationship ___________________________________________________________________________________ Phone __________________________ Address _________________________________________________________________________________________________________________________
Family Physician Name ________________________________________________ Phone _____________________________________________________ Dentist/Orthodontist Name ____________________________________________ Phone _____________________________________________________
Parent/Guardian Authorizations: This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment; to release any records necessary for insurance purposes and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. I understand that all reasonable attempts will be made to contact me as soon as possible after the condition necessitating treatment arises, and, that failing to reach me, all reasonable attempts to contact the alternate listed above will be made. I understand that all reasonable precautions will be taken for safety at all times. I further release the West Virginia Baptist Convention, the Camp Cowen Board, the Parchment Valley Board of Directors, the West Virginia American Baptist Youth, and all persons associated with these organizations from any liability associated with any accident, injury or disease to the person who is the subject of this form. SIGNATURE OF PARENT/GUARDIAN OR ADULT CAMPER/STAFFER___________________________________________________________
SECTION II – NOTARY
STATE OF WEST VIRGINIA
County of, __________________________________________________________ , ____________________________________________________ to wit:
I, a qualified Notary Public, in and for the County aforesaid, hereby certify that the person whose signature appears above, did on this date, appear
before me, after begin duly sworn or affirmed, and reading this document in its entirety did affix his or her signature hereto in my presence.
_________________________________________ NOTARY PUBLIC Date Executed________________/2012
My Commission Expires:________________Please imprint seal in the area to the right: SECTION III – TRANSPORTATION
In order to protect your child, please provide us with the following information:
Who will be picking your child up at the West Virginia Baptist Camp at Cowen at the close of camp?
Is there anyone in particular whom you do not want to pick your child up at the close of camp? If yes, please list the name(s) below:
THANK YOU FOR HELPING US PROTECT YOUR CHILD.
SECTION IV – INSURANCE INFORMATION
Is the participant covered by family medical/hospital insurance: YES NO
If so, indicate carrier or plan name _______________________________________________________________ Group # _________________________
Carrier Address ___________________________________________________________________________________________________________________
Address for Claims ________________________________________________________________________________________________________________
Poicy Holder’s Name __________________________________________________ Relationship to participant ____________________________________
Policy Holder’s Social Security # or Insurance ID # _________________________ Employer ___________________________________________________ SECTION V – MEDICATIONS AND RESTRICTIONS
Will camper be taking medications while at camp? Yes No (Medications include prescription, over-the-counter, vitamins, inhalers, etc.)
If camper will be taking medications while at camp, please list all (prescription and non-prescription). Include the medication name,
prescribing physician, physicians’ phone number, and the dosage instructions. Use an additional sheet if needed. When you check-in
at camp, please provide all medications in their original packaging that identifies the prescribing physician (if prescription drug), the
name of the medication, the dosage, and frequency of administration.
Prescribing Physician ___________________________________________________________________________ Phone ___________________________ Special Instructions or Considerations for Minor Illness Unless specific instructions are provided, camp health care staff will treat minor illnesses with over the counter medications. If illness persists, parents will be notified. ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________
Identify any medications the camper takes during the school year that the camper does not/may not take during the summer: ___________________________________________________________________________________________________________________ I grant permission for the camp health director to administer: (Please circle your choice for each over-the-counter medicine below) Aspirin Yes No
NSAID (ibuprofen/Advil, Motrin) Yes No Cough Medicine Yes No
Parent Signature for over-the-counter administration__________________________________________________
SECTION VI – ALLERGIES
1. Hay Fever 2. Poison Ivy/Oak 3. Insect Stings 4. Food 5. Penicillin 6. Other Drugs 7. Other________________________
Please specify allergy. Describe reaction and treatment. _______________________________________________________________________________
Any change to this form should be provided to camp health personnel upon camper’s arrival in camp.
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