Camp Subiaco

405 N. Subiaco Avenue
Subiaco, Arkansas 72865
Telephone: (479) 934-1001
Email: campdirector@campsubiaco.org

Medical History Form

Please fill out one form per Camper

Camper's Information:
*Last Name: A value is required.

* First Name:

* Registration #: A value is required.
— Number provided on Camp Registration Confirmation Form

Parent's Information:
* Last Name:

* First Name:

Emergency Contact Info:
* Contact:

* Relation:

* Phone #: 000-000-0000

Insurance Info:
Carrier:
Policy #:      Group #:
Name of Insured:
Have no insurance:
Authorization from primary physican required prior to treatment:

Health History: (Select the correct repsonse)

Ear Infections: Select One.. Yes No	Chicken Pox: Select One... Yes No	Poison Ivy Reactions Select One... Yes No
Asthma: Select One... Yes No	Asthma: (Inhaler Required) Select One... Yes No	Heart Problems: (Murmurs) Select One... Yes No
Seizures: Select One... Yes No	Diabetes: Select One... Yes No	Use Behavior Medications: Select One... Yes No
Depression: Select One... Yes No	Skin Conditions: Select One... Yes No	Reacts to Bug/Insect bites: Select One... Yes No
Food Allergies: Select One... Yes No	Hypersensitivity to Sun: Select One... Yes No	Other Medical Needs: Select One... Yes No

If you answered "Yes" for any of the items listed above, then please provide a detailed description of the Medical Issue/Need:

List all Allergies:

List Surgeries Serious Injuries (Give dates):

List restricted activities:

Please list all medication. All medication must be in the original pill bottles labeled with the child's name, pharmacy, medication name
and dosage. Only send the exact amount of medication that your child will need for the six days. No medication will be returned.

Medicine (Name)	Dosage	Interval	Comments

IMPORTANT: Please notify the camp management if this camper has been exposed to any communicable disease during the three weeks prior to
camp attendance.

Parents Authorization
This health history is correct as far as I know and the person herein described has permission to engage in all prescribed camp activities, except as
noted by the examining physician and me. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected
by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above.

Signature:

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