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Summer Camp Health and Consent Form

Gather everything the camp team needs about each child before arrival: family contacts, medical cover, family doctor and dentist, vaccinations, medication and activity limits. The family authorises participation and emergency medical care with a signature. Everything lands in one record the staff can open from a phone.

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In the Claude connectors directory

Page 1

About the camp

Camper details

Date

Camper name

First Name

Last Name

Date

Gender

Girl Boy Other Prefers not to say

Parent or guardian name

First Name

Last Name

Landline number

Mobile number

Home address

Street Address

City

State / Province

ZIP / Postal Code

Work phone number

Work address

Street Address

City

State / Province

ZIP / Postal Code

Alternative emergency contact

Emergency contact name

First Name

Last Name

Phone Number

Mobile Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Page 2

Medical cover

Is the camper covered by an insurance policy?

Yes, the camper is covered No insurance cover I am not sure

Policy number

Insurance company name

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Family health professionals

Family doctor name

First Name

Last Name

Phone Number

Family dentist name

First Name

Last Name

Phone Number

Camper health history

The camper is fit to take part in active camp activities

Yes, with no restrictions Yes, with some limitations No, not fit to take part

Has the camper been exposed to a communicable disease in the past six months?

Yes No I do not know

If yes, please specify

Are the camper's vaccinations up to date?

Yes, fully up to date No, not up to date Has a medical or religious exemption

Date of the last tetanus shot

Previous hospital stays or surgeries

Activity limits advised by a doctor

Page 3

Guardian authorisation and consent

Parent or guardian signature

Sign here

Name of the signing parent

First Name

Last Name

Date Signed

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