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Camp Health Form
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Outdoor Adventure Summer Day Camp
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Camp Health Form
2024 Camper Health Form
Camper's Name
*
First
Last
Birth Date
*
MM slash DD slash YYYY
Age of Child on First Day of Camp
*
Camp Session/Dates Attending
*
Allergies
*
No Known Allergies
Food
Medication
Environmental
Other
If yes, please describe allergy:
* If child has no severe allergy or asthma, please skip to "Restrictions or Adaptations" *
SEVERE ALLERGY: List each medication separate below. All must have pharmacy label!! If needed, TWO Epipens should be brought to camp. The camper must be trained in the use of the Epipen. Camp and staff will assist in administering medication if needed.
List the Severe Allergy and the Camper's Symptoms
*
Check the Relevant Statement:
Camper does not need to carry medication at all times, therefore the medication shall be locked up in the office
Camper should have medication(s) with him/her at all times
ASTHMA: List each medication separately below. All must have the pharmacy label!
Check the Relevant Statement:
Camper does not need to carry medication at all times, therefore the medication shall be locked up in the office
Camper should have medication(s) with him/her at all times. Camp staff must monitor each dose.
Restrictions or Adaptations: Campers can participate:
*
Without restrictions
With these restrictions/adaptations
Immunization History - Are all immunizations up to date?
*
Yes
No
** If your camper is not fully immunized you will need to provide a certificate waiver, which can be obtained at your local health department. These forms will need to be mailed, faxed, or emailed to Dahlem prior to attendance.
Medication
*
This camper does not take any medication
This camper takes medication
If your camper needs to take prescription or nonprescription medicine while at Dahlem, the camper’s parent/guardian will need to complete the boxes below. All medication must be in its original container or package, placed in a clear Zip-Loc plastic bag, and clearly labeled. The camper’s name must be printed on the label of all prescription medication. Please be sure to check that medication does not expire before the camper’s last day in our program. If possible, all medications should be given under the supervision of the parent/guardian. When this is not possible, Dahlem Camp Director may give prescribed medication as an assistance to parents/guardians.
Please List All Medications
** List must include: Name of the Medication, Reason for taking it, When it is given, Dosage, and Date the medication was started
Mental, Emotional, and Social Health
Check all that apply:
Is/has been treated for ADD/ADHD
Is/has been treated for emotional/behavioral difficulties
Is/has been treated for an eating disorder
Has seen a professional to address mental/emotional health concerns in the past 12 months
Has had significant life event that continues to affect camper
Explain any of the items checked above.
Explain any of the items checked above.
What is the best method for our camp staff to work with your camper?
What is the best method for our camp staff to work with your camper?
Medical Insurance Information
This camper is covered by family medical/hospital insurance.
This camper is not covered by insurance
Primary Policy Holder
Relationship to Child
Health Insurance Company
Insurance Number
Physician’s Name
Physician’s Phone Number
General Release of Liability and Authorization for Treatment
By submitting this health form I attest this health history is correct to the best of my knowledge and the person (camper) herein described has permission to engage in all camp activities except as noted. These completed forms may be copied for use within Dahlem camp program. In consideration for being allowed to participate in the Dahlem Conservancy’s programs, I agree to assume the risk of such activities and programs and I further agree to hold harmless the Dahlem Conservancy and its staff members conducting the activities from any and all claims, suits, losses, or related causes of action for damages including, but not limited to, such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities. I grant permission for me or my child to participate in all planned camp activities understanding that competent leadership is provided. The Dahlem Conservancy is not responsible for lost, stolen, or damaged personal articles. I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the camper mentioned above. If there is a religious objection to consenting to receipt of emergency medical or surgical treatment, the authorized person shall submit a written statement to the effect that the camper is in good health and that the person signing assumes the health responsibilities for the camper. This completed health form may be copied for use by the camp.
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Home
About Dahlem
Employment Opportunities
Newsletter
Visiting Dahlem
Trail Maps
Habitat conservation
Who We Are
What We Do
Who We Serve
Dahlem Conservancy 990
Education Programs
Introduction to Beekeeping
Little Acorns Nature Preschool
Little Acorns Nature Preschool Registration
Scholarship Application
Tuition Payment
Mighty Naturalist Program Series
Annie’s Big Nature Lesson
School Programs
Camp
Camp Registration Form
Camp Release Form
Camp Health Form
Campership Financial Assistance Application
Important Info for Camp Families
Events
Support
Berlet Fund For Nature
Donate
Dahlem + Your Legacy
Sponsor
Membership
Member Survey
Volunteer
Ecology Farm & Garden
Remembering Betty Dahlem Desbiens
Contact
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