Counselor Health Form
Camp Good News - Health Form (rev. in 2009)

Camper’s Name: ___________________________________________

Camp Date: ______________________________

Male _________ Female _________ Age ________ Date of Birth ______/______/_____

Beginning in 2010 medical records from previous years are no longer acceptable.
Please give all dates of Immunization for (or include a copy of ) shot records:

Which of the following has the participant had? Vaccine Dates: (M/Yr )

DPT ____ ____/ ____ ____ ____ ____
Vavivax (Chicken Pox) ____ ____/ ____ ____ ____ ____
Measles, Mumps, Rubella ____ ____/ ____ ____ ____ ____
Hepatitis C ____ ____/ ____ ____ ____ ____
Tetanus ____ ____ / ____ ____ ____ ____
Hepatitis A,B,C ____ ____/ ____ ____ ____ ____
Polio ____ ____ / ____ ____ ____ ____
Haemophilus Influenza B ____ ____/ ____ ____ ____ ____
TB Mantous Test ____ ____ / ____ ____ ____ ____
Date of last test ____ ____/ ____ ____ ____ ____
Result: Positive Negative ____ ____/ ____ ____ ____ ____

Allergies: medications ________________________________
type of reaction __________________________________
food/other____________________________________
type of reaction ________________________________________

Emotional or Behavior Problems: ____________________________________________________________________

Medication Requirements:All medicine must be in original container labeled with camper’s name.
Enclose medications in a ZIP-LOC bag labeled clearly with camper’s name and give to nurse at registration.

Medication:___________________________________________________________________
Dosage:______________________________________________________________________
Reason:__________________________________

Permission to Treat Camper:
Below are the medications that are kept in stock at the nurse’s station.

Please check the types your child may receive.

Tylenol _______Antacid Medicine _______Antihistamine (allergy)________
Ibuprofen ______Robitussin DM (Cough) _______Decongestion

Special Health Considerations: _______________________________________________________________________

Disabilities: _______________________________________________________________________________________

Camp Good News Clarification: Our camper’s insurance begins where yours terminates.
It is only valid when your policy has been extended to its limit.
In the event you have no personal organizational insurance,

Camp Good News can arrange adequate emergency medical coverage (with $5,000 maximum coverage).

The Health History is correct as far as I know, and the person herein has my permission to engage in all camp activities, except as noted by me and/or attending physician. I give my permission to the physician selected by the Director of Camp Good News to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for the child named above. I also give permission to the Camp Good News Health Officer to give routine, non-surgical treatment.

___________________________________________
Signature of Parent or Guardian

_______________________
Date