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Campsawtooth.org


Parent/Guardian to be contacted in case of emergency:

EMERGENCY CONTACT: In case you cannot be reached, please notify:
Name

HEALTH HISTORY: Camper health and medical information needs to be made known to the camp. Camp personnel will
hold this information in confidence. If insufficient space is provided, please attach additional paperwork.
ALLERGIES: List all known allergies and describe reaction and management of the reaction.
Medication Allergies:
Food Allergies or Special Diet Needs:
Other Allergies: (include insect stings, hay fever, asthma, animal dander, etc.)
Are there any medical conditions or restrictions we should be aware of? If so please explain:
Explanation: (Attach additional sheet if needed)
HEALTH INSURANCE:
Is this camper covered by family health insurance?

IMMUNIZATIONS:
When was your child’s last tetanus shot? ________________________________________
NON-PRESCRIPTION MEDICATIONS: Camp Sawtooth keeps over-the-counter medications stocked for campers who
may need them. Please check those medications that your child may take/use if needed. These will be administered by
the Health Care Staff.
____Acetaminophen (Tylenol)
MEDICATIONS: List ALL medications including over-the-counter or non-prescription drugs taken routinely. Bring sufficient
medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician
(if a prescription drug), the name of the medication, the dosage and the frequency of administration. The camper’s name
must be written on all containers. Please do not take your child off regular medicines while at camp. Attach additional
paperwork if needed. Identify any medications taken during the school year that participant does/may not take during the
summer.
Medication #1

Medication #3

EPI PENS or INHALERS (Parent or Guardian please initial)

I give my child permission to carry an Inhaler and to self-administer. _____ I give my child permission to carry an Epi pen and to self-administer. _____ Health Care Staff should keep my child’s Inhaler or Epi pin to help determine when needed. _____
EMERGENCY AUTHORIZATION AND LIABILITY RELEASE:

This health history is correct so far as I know, and the camper described above has permission to engage in all camp activities except
as noted. I have familiarized myself with the camp program and events and understand that all activities are completely voluntary. I
recognize the inherent risk of injury in camp activities.
I understand that Camp Sawtooth has taken extensive safety measures, including the certification of its staff in first aid and CPR, as
well as making every effort to aid the safety of all camp participants. However, I also recognize that Camp Sawtooth cannot insure or
guarantee that the participants, equipment, grounds and/or activities will be free of accidents or injuries.
I am aware and have instructed my child in the importance of knowing and abiding by the camp’s rules and regulations and do release
Camp Sawtooth from all liability for any injury to the camper. I understand that transportation to and from camp (and any liability
thereof) is the responsibility of the camper, and not that of Camp Sawtooth.
I give permission to the Camp Health Care staff to (1) administer the camper’s routine medications, as needed, and over-the-counter
medications for minor illnesses or discomfort; (2) provide appropriate first aid for minor injuries; and (3) seek further treatment from local
physician or hospital if condition warrants.
In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to hospitalize,
secure proper treatment for, and to order injection and/or anesthesia and/or surgery for the camper named above. This completed form
may be photocopied by the camp to have a second set available for Camp Sawtooth
I give permission for Camp Sawtooth to use any photo, video, or interview taken at camp to be used to illustrate report, promote and
advertise Camp Sawtooth.
Signature of Parent/Guardian

MEDICAL FORM MUST BE COMPLETED AND RETURNED AT LEAST TWO WEEKS BEFORE CAMP

BEFORE MAY 15TH
AFTER MAY 15TH

Source: http://www.campsawtooth.org/cst/documents/2012/NewMedicalForm.pdf

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