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What Happens at JAZZ CAMP

Camp Heebie Jeebies
 
Health Form    

 


Bring this completed form to Camp

Camp Heebie Jeebies

Health and Liability Release Form

 

Student _______________________________ Date of Birth _______  Phone_________________

 

Address ____________________________________________      Female ______  Male ________

 

City , State, Zip__________________________________  Email___________________________

 

Is this participant in general good health and able to participate in all normal Camp Heebie Jeebies activities?

 

Yes_________     No_________  (If NOT, please submit a statement indicating limitations)

 

Name of Family Physician __________________________________________________________

 

Address/Phone____________________________________________________________________

 

 

PARENT/GUARDIAN:  Please read carefully and complete this section:

While participating in activities at Camp Heebie Jeebies, each student is assumed to be voluntarily performing activities for which he/she assumes all risk, consequences, and potential liability.    By signing this form, I hereby release Camp Heebie Jeebies and Camp David Jr.  and their agents from any and all claims by reason of accident, injury, illness, death, or any other consequences arising or resulting directly or indirectly from participation in activities at Camp Heebie Jeebies held at Camp David Jr., Lake Crescent, WA.

 

In case of a medical emergency, I understand that every effort will be made to contact parent(s) or guardian of participants.  In the event that I cannot be reached, I hereby give permission to the physician selected by the Camp Nurse and/or the director of Camp Heebie Jeebies to hospitalize, secure proper treatment, for and to order injection, anesthesia or surgery for my son/daughter as named herein.  I also give permission for the release of medical records to an attending physician in case of illness or accident. 

 

The procedure we follow for medical emergencies is to give first aid immediately and then transport the person to the Port Angeles medical center.  If an ambulance is required, staff members will call 911, and the injured person will be driven toward Port Angeles to meet the ambulance midway (the distance is 30 miles from the camp to Port Angeles).

 

SIGNATURE OF PARENT/GUARDIAN __________________________________________

 

PHONE _______________________________     E-Mail address   ______________________

 

HEALTH INSURANCE CO. ___________________________ POLICY # _______________

 

DATE _____________________

 

Please fill out the questions on the next page.
IMMUNIZATION HISTORY:

(All immunizations are the responsibility of the student in consultation with family physician or clinic)

 

Please give dates:

 

DPT _______________         DPT Booster ____________             Tetanus Booster__________

 

Polio Series _____________________________________             Polio Booster ____________

 

MMR __________________________________________                        MMR Booster ___________

 

ALLERGIES/CHRONIC CONDITIONS: 

(Please write YES or NO next to each)

 

Hay Fever ______________             Sulfa ______________           Fainting ________________

 

Convulsions ____________               Asthma ____________          Poison Ivy ______________

 

Bee Sting ______________               Other __________________________________________

 

If you answer YES to any of the above, please submit a statement detailing how the student has been treated and which medications have been used.

 

OPERATIONS OR SERIOUS INJURY: (Please include dates)_________

 

 

 

COMMUNICABLE DISEASE:  Please notify Camp Director if this student has been exposed to any communicable disease during the three weeks prior to attendance at Camp Heebie Jeebies.

 

DIETARY REQUIREMENTS:  Please write below any dietary requirements that are essential for the student’s well-being.  We are not able to provide a complete “vegan” diet; however, there are salads, fruit, fresh-cut vegetables, and peanut butter/jelly sandwiches available at every meal.  If there is a particular food item that the student must have each day, it would be wise to bring it along.  We have refrigeration and freezer space available.

  

Revised 7-11-10