Medical Profile Form

Please note that we require a copy of your insurance card along with this medical profile form. This can be submitted separately to our postal address or emailed to cvp@vesperpoint.org.

1. Camper Information
Camper Name
Street Address
City
State & Zip
Gender Male Female
Session
1 June 11 - 16 (rising 3rd-6th graders)
2 June 18 - 23 (rising 3rd-6th graders)
3 June 25 - 30 (rising 7th-10th graders)
4 July 9 - 14 (rising 3rd-6th graders)
5 July 16 - 21 (rising 3rd-6th graders)
6 July 23 - 28 (rising 7th-10th graders)
Age
Date of Birth (eg, 09-30-2003)
Height (eg, 4' 2")
Weight lbs
Tetanus Shot I have / have not had a tetanus shot in the past 5 years.
  If you have, enter date: (eg, 02-25-2012)
2. Parent/Guardian Information
Parent/Guardian #1...
Name
Home Phone
Work Phone
Cell Phone
Occupation
Relation to Camper
Parent/Guardian #2...
Name
Home Phone
Work Phone
Cell Phone
Occupation
Relation to Camper
3. Emergency Contact
List an Emergency Contact other than parent/guardian...
Name
Home Phone
Work Phone
Cell Phone
Relation to Camper
4. Insurance Information
IMPORTANT: A copy of both sides of insurance card must be submitted seperately.
Name of Insured
Employer
Insured SS#
Insurance Company
Policy #
5. Allergies
Drugs
Food
Other
6. Doctor & Immunization History
Camper's Doctor
Doctor's Phone
Are Immunizations
Current?
Yes No
7. Medical History
Has your camper had or does your camper currently have:
1. A chronic or recurring illness/condition? Yes No
2. Food allergies or restrictions? Yes No
3. Recent Surgery? Yes No
4. Diabetes? Yes No
5. Frequent headaches or migraines? Yes No
6. Asthma? Yes No
7. Frequent ear infections or tubes? Yes No
8. Problems with sleepwalking? Yes No
9. Heart murmur? Yes No
10. Problems with bed-wetting? Yes No
11. Skin problems? Yes No
12. Other? Yes No
If you answered "Yes" to any of the above questions, please explain below, noting the number of the question.



Is there any other information concerning your camper's physical, emotional, mental health or behavior that we need to be aware of? Please describe below. All information is confidential and is used to help us better serve the needs of your camper.

8. Important Note About Lice
We thoroughly check all campers for lice upon arrival. If any nits are found, we will discreetly ask the parent to take the child home until he/she can be treated and return nit-free. Campers will be asked to leave camp for a minimum of 6 hours in order to rectify this rectify this problem. See our Camp Policies for more information.
9. Camper Medication
Medications will not be administered on Monday morning or Saturday morning.

All pharmacy medications must be brought to camp in the original container with the camper's name and correct dosage. All over-the-counter medications must be brought in the original containers. Campers are not allowed to keep any medication with them in the cabin unless authorized by the camp nurse.

List all over-the-counter medications that you DO NOT want your camper to receive:



List all medications that your camper will take at camp:
Medication Dosage Frequency Reason for Drug
All Medication (both prescription and over-the-counter) must be checked in with the Camp Nurse at the time of registration. Prescription medicines MUST be in a pharmacy-labeled container, including dosage and instructions, with the camper's name as the primary patient. Please send a 7-Day pillbox to put meds in.

Note: If your camper has been on medication to help control behavior, and you have chosen to take him/her off for some reason, we need to know of the condition and the medication used for controlling it.
10. Parent Liability Release/Hold Harmless Agreement and Authorization of Emergency Medical Treatment

Each camper must confirm their understanding of this agreement. Please read carefully and sign your name below to indicate your acceptance.

Applications will not be accepted without your digital signature.

Finished?

Have you thoroughly checked your information?

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Please note that we require a copy of your insurance card along with this medical profile form. This can be submitted separately to our postal address or emailed to cvp@vesperpoint.org.