Lionswildcamp.org

LIONS WILDERNESS CAMP
❑ Camper
Health History and Examination Form - Required each year and must be submitted at least 3 weeks prior to camp.
This side to be filled in by Parents / Guardians for minor age applicants
Please PRINT or TYPE. It is very important that we are able to read this information.

Last name: ________________________________ First name: _____________________ Middle initial: ___
Primary emergency contact:
Name of Physician:
Name of Dentist:
Health Insurance Carrier:
--Include copy of front and back sides of medical insurance carrier cards--
IMPORTANT - THE FOLLOWING MUST BE COMPLETED FOR ATTENDANCE
To the best of my knowledge, this health history is correct and the person herein described has my permission to engage in all camp activities except as noted. Furthermore he / she has no history of mental illness or behavioral issues that would compromise a positive camp experience. Authorization for Treatment: I hereby give permission to the medical personnel selected by the Camp Director
to order x-rays, routine tests, treatment, and necessary transportation for my child. In the event I cannot be
contacted in an emergency, I hereby give permission to the physician selected by the Camp Director or designated
medical personnel to secure and administer treatment, including hospitalization, for my child as named above.
Campers' vaccination record containing inoculation dates will be presented upon arrival at camp. Completed
medical forms may be photocopied for trips out of camp.
I hereby give permission for the camp medical staff to dispense OTC (over-the-counter) medication as needed to
my child as checked below. Dosages will be administered according to directions on the container unless a
physician directs otherwise.
❍ Cough drops / syrup ❍ Stool softener / Laxative ❍ Other ______________________ ❍ Other___________________________________
Signature of Parent / Guardian

I understand and agree to abide with any restrictions placed upon my camp activities as noted on this form and
agree to take prescribed medications as indicated.
Signature of Camper:
Note: Because medication cannot be secured in cabins, we consider all medications as dangerous to campers. Therefore, we require all prescribed and OTC medications be left with the nurse. All medications must be in original containers with instructions for administration in English. The medications will be available and administrated anytime they are needed. Unused medications shall be returned at camp checkout. PLEASE BE SURE THAT YOUR PHYSICIAN COMPLETES PAGE 2 and FORM IS SUBMITTED PRIOR TO CAMP. Medical Exam and Evaluation -- to be filled out by medical personnel only

Name of Applicant
Date examined
Please record the specific date (month / year) of the basic immunization and the most recent booster doses for TETANUS. Conditions: (Check all that apply and indicate continuous or date of last occurrence)
❍ ADD / ADHD
________ ❍ Back Injuries / problems ________ ______ ❍ Psychiatric counseling/hosp __________❍ Autism Please explain any checked items above or conditions not listed __________________________________________ Has this applicant had any serious injury, illness or surgery during this last year? ____ If Yes, explain: _________________ Allergies (Check all that apply)
If immediate medical attention is required for any allergy, specify treatment: *If epinephrine is required, please give to camp nurse. Epinephrine MUST have a physician order on file to give. Does the applicant require a special diet? ________If yes, please explain: _______________________________________ Medications: Please list all medications to be continued while at camp.

 Individual requires no regular medication.
Is there any medical reason why the applicant should not hike? (Hiking is an integral part of the camp program, as the camp elevation may range up to 300 ft. from the highest to lowest area.): HEALTH CARE RECOMMENDATION BY LICENSED PHYSICIAN (REQUIRED)
I have examined the above applicant within the past two (2) years. This applicant appears in good physical condition and able to participate in an active camp program at an approximate altitude of 6,000 ft. I have no reason to restrict participation in any camp activities except as listed: ________________________________________________________________________

Source: http://www.lionswildcamp.org/applications/2010Camper-Med-form.pdf