Youth Camp Health History - Camper

Sacred Heart Summer Camp 2021

Child's Name Child's Name First Last
Current Residence Current Residence
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact Information
Emergency Contact (Parent or Legal Guardian) Emergency Contact (Parent or Legal Guardian) First Last
Phone (for contact above) Phone (for contact above) - ### - ### ####
2nd Emergency Contact (other than parent/guardian above) 2nd Emergency Contact (other than parent/guardian above) First Last
Phone (for 2nd contact) Phone (for 2nd contact) - ### - ### ####
Primary Care Physician or other provider of medical care:
Phone (for medical care provider above) Phone (for medical care provider above) - ### - ### ####
Health Information
Are there any health problems including physical, psychiatric, or behavioral problems of which we
need to be aware?

Are there any health problems including physical, psychiatric, or behavioral problems of which we
need to be aware? NO YES, and youth camp participation was discussed with the camper’s healthcare provider including considerations related to risk of COVID-19
If YES, explain health problems and any considerations:
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive? NO YES, explain:
If YES, explain:
Immunization Information

Must list current residence above
For campers who currently reside within the United States, a United States territory, or the
District of Columbia: Does the camper have any immunization exemptions because of a parental
or guardian objection or medical contraindication?

For campers who currently reside within the United States, a United States territory, or the
District of Columbia: Does the camper have any immunization exemptions because of a parental
or guardian objection or medical contraindication? NO YES, list:
If YES, list:
Parent or Legal Guardian Signature:

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY

Youth Camp Health History - Camper

Youth Camp Health History - Camper

Emergency Contact Information

Health Information

Immunization Information