Heartland Hockey Camp

Campers Health History

Last name First name

Date & camp attending

Will your child celebrate his/her birthday while at camp/ date

Person to notify in case of emergency, if parents are not available

Name Phone # Relationship

Camper’s Doctors name Telephone #

Camper’s Dentist name Telephone #

Date of last Doctors Exam Date of last Tetanus shot…….

ALL MEDICATIONS (EXCEPT INHALERS) MUST BE TURNED IN TO THE MEDICAL STAFF, TO BE DISPENCED BY THEM. PLEASE LIST ANY MEDICATIONS YOU ARE SENDING WITH YOUR CAMPER

1. Medication purpose……………………. 2. Medication purpose…….........................

Allergies: Drugs……………….. Food………………... environmental hay fevers………….. Insect bites or stings…………… Other……………… Will your child be bringing an Epi Pen……. If yes does your child know how to use it ………….. (CAMPERS BRINING OWN EPI -PENS SHOULD ASO BRING A FANNY PACK TO CARRY IT IN)

Any other medical conditions...

Is there any information on the camper’s family structure that would be important for the staff to know? (Parents separated, divorced, custody issues, loss of family member, etc.)

The health history listed above is current, as far as I know. If a serious illness or injury develops, medical and or hospital care will be given, staff members are not responsible in case of an accidental injury, or illness. Further, I understand that in case of medical emergency I will be notified. In the event that I cannot be reached, I hereby give permission to the attending physician to hospitalize, secure proper treatment for, and to order injections anesthesia or surgery for child named above.

Signature of Parent or Guardian…………………………Date……………………..