Please complete all information (use one form for each camper), sign, date, and return to:
Camp Cherith Registrar,
26 Broadfield Dr.
Newark, DE 19713
(302)738-8186 quail@campcherithinpa.org
To be filled in by camper's parent / guardian, staff member, or adult camper.
Name
Last
First
Middle
Date of BirthAge
Sex
Parent / Guardian (or Spouse)
Home Phone
Home Address
Business Phone
If not available in an emergency, notify:
NameRelationship
Home Phone
AddressBusiness Phone
OR NameRelationship
Home Phone
AddressBusiness Phone
HEALTH HISTORY: (Check - giving approximate dates)
Bleeding/Clotting DisordersDiabetes
Ear Infections (frequent)Epilepsy or Convulsions
Heart Defect/Disease
High Blood Pressure
Diseases Chicken PoxMeasles
German MeaslesMumps
Allergies AsthmaFood
Hay FeverInsect Stings
Ivy Poisoning, etc.Penicillin
Other (list)
(For Female): Has this person menstruated?
If not, has she been told about it?
If so, is her menstrual history normal?
Special considerations
List date(s) and describe:
Disability or chronic/recurring illness
Operations or serious injuries
Recent Illness or hospitalization
Name of family physicianPhone
Name of dentist/orthodontistPhone
Name of family medical/hospital insurance carrier
Policy or group numberName of the policy
CURRENT MEDICATION
Name of medicationDosage
When takenReason for taking
Name of medicationDosage
When takenReason for taking
Name of medicationDosage
When takenReason for taking
Name of medicationDosage
When takenReason for taking
Name of medicationDosage
When takenReason for taking
NOTE: All medication brought to camp (listed above), including vitamins and asprin, must be labeled
with directions for use. Prescription medication must be in original container with user's name
printed on label.
AUTHORIZATION FOR TREATMENT MUST BE COMPLETED
This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed
activities except as noted.
I hereby give permission to the physician selected by the camp director to order X-rays, routine tests, and treatment for the
health of my child, and in the event I cannot be reached in an emergency, I hereby give permission to the physician selected
by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for
my child as named above. This form may be photocopied for use out of camp.
Camper's Name_______________________Date Examined___________Cabin or Tent______________
IMMUNIZATIONS--Required immunizations must be determined locally. Record the date (month / year) of immunization
and / or most recent booster.
IMMUNIZATION
Date Last Received
IMMUNIZATION Date Last Received
DTP Series Measles
Mumps Polio
Rubella (German Measles Tetanus
Tuberculin test (most recent)
Other Date Last Received
Other Date Last Received
Other Date Last Received
Other Date Last Received
HEALTH EXAMINATION (To be completed by licensed physician)
Examination is for determining fitness to engage in camp activities. Reference to earlier examination for some other purpose is
acceptable.
I have examined the applicant on _____________________and reviewed the health history.
Date Examined
In my opinion, the applicant's condition does [] does not [] hinder
his or her participation in an active camp program.
Does applicant have any conditions which might limit participation in swimming, hill climbing, team sports, and other strenuous
activities?
______Yes _____No Explain_____________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
The applicant is under the care of a physician for the following condition(s):__________________________________________________________________
______________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Current treatment (include current medications):_________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Recommendations while at camp:
Treatment to be continued at camp:___________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Medications to be administered at camp:_______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Medically prescribed meal plan or dietary restrictions:_____________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Any restrictions? (swimming, diving, strenuous
activity):_______________________________________________________________________________
_____________________________________________________________________________________________________________________________
____________________________________________________
______________________________________________________
Examining Physician's Signature
Print Physician's Last Name
Phone( )__________________________________________ _____________________________________________________
Address
Date of Form Completion________________________________
_____________________________________________________
City
State
Zip
By______________________________________________________________________________________________________
Initial if completed by nurse or assistant.