Health History
To be completed by Parent or Guardian every year.
Name of Camper
*
First Name
Last Name
Session(s) Attending
*
Junior Camp
Young Teen Camp
Equestrian 1
Equestrian 2
Equestrian 3
Equestrian 4
Cowgirl 1
Cowgirl 2
Adventure Camp
Guy Stuff Camp
Gender
*
Male
Female
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Grade in Fall 2025
*
Weight
*
Height
*
Personal History
Allergies
Appendicitis
Asthma
Chicken Pox
Mumps
Heart Trouble
Hearing Problem
Kidney Trouble
Measles; Regular
Measles; German
Scarlet Fever
Whooping Cough
Muscle or Nerve Disorder
Pneumonia
Rheumatic Fever
Venereal Disease
Seizures
Tonsillitis
Tuberculosis
Diabetes
Other (list below)
Other Health History Not Listed Above
Allergies to Medications
*
Other Allergies
*
Operations or Injuries
*
History of emotional or behavioral disturbance
*
Special conditions to be watched for, such as bed wetting, fainting, sleep walking etc.
*
List medication and purpose of medications that your child will be bringing to camp.
*
Has girl been told about menstration?
Yes
No
Has girl menstruated?
Yes
No
The camp health supervisor will be dispensing over the drugs (such as Tylenol, cough drops) if needed. Are there any over the counter drugs that your child should NOT receive?
Name of child's health insurance
Policy Number
Name of Insured
Immunizations Dates - List initial immunization AND latest booster dates. (Or send immunization print out to skylodgecamp@gmail.com)
In an emergency, I hereby give permission to the licensed physician selected by Sky Lodge Christian Camp to hospitalize, secure proper treatment, anesthesia, or surgery for my child named on this form. I also consent to non-surgical medical care.
*
Mom's Cell Phone
Please enter a valid phone number.
Dad's Cell Phone
Please enter a valid phone number.
Other emergency contact name if mom and dad cannot be reached.
Other emergency contact phone number.
Please enter a valid phone number.
Submit
Should be Empty: