Home Phone: _______________ Age:__________

Address: _________________________________

City/State/Zip: _____________________________

List any allergies camper may have to food, pollens or antibiotics:

Do you know of any physical disorder that would prevent this camper from participating in a vigorous camping program?

Does he/she have a tendency to bed wet regularly?

Does he/she ever walk in his or her sleep?

Has he/she been given tetanus injections of boosters recently and if so when?

Has his/her appendix been removed?

Are there any medications or treatments your child is currently taking of which we should be aware or which you will want us to supervise during his or her stay at camp?

Do you know specifically if your camper is allergic to bee stings, penicillin, animal (horse, dog, cat, etc.) hair, etc.?

In case of emergency where you cannot be reached, is there some other close relation or party whom we might contact? Please provide phone number.

This child will participate in a program of vigorous camping activities including swimming, horseback riding, climbing, jumping, hiking, etc. Please state, if in your opinion, this child is in physical condition to take part in such a program of strenuous outdoor activities, and if not, what specifically should be avoided:

Any additional remarks?

A note to parents:

We have two excellent, well staffed clinics in Nashville. We'll use these facilities in the event of any minor scrapes or aches, etc. Bloomington and Columbus Hospitals are each about 30 minutes from Camp, should we need additional care. We will notify you if your child has gone to a doctor for any reason. The Camp has medical insurance to help cover expenses here, but this insurance has limits and you may need to cover a minimal deductible amount if your child does need to see a doctor. Should any fees exceed our Camp coverage limits, your own family policy would need to kick in here. Please sign and date to indicate this arrangement is agreeable with you. Also indicate your insurance carrier and policy number.

Parent/ Guardian Signature _________________ Date _______

Family Medical Insurance Carrier ________________________

Policy # ___________________________________________

Name of your Family Doctor ____________________________

Doctor's phone # _____________________________________

If this Camper is to be taking ANY medications during camp, it is essential that we have written instructions regarding administration of these medicines from you, the parent/guardian. Please complete the following if this situation will apply to your camper

Camper's Name

Medication(s)

Special care of medications (refrigeration, etc.)

Any special reactions/symptoms to watch for?

Refill information

Remarks

CAMP USE ONLY

Camper's Name

Age

______Examination of arriving camper/staff by Camp Health Supervisor.

______Skin ______Eyes ______Temperature ______Throat

______ Ears ______ Other

Existing condition(s) to be watched closely:

Date examined ____________

Signature of Heath Supervisor _____________________________________