Health Form

Health Form

Extensive Counselor-in-Training Health Form to collect health information on the camp participants. Form Preview
  • CIT Health Form

    HFM Camping Adventures
  • Personal Information

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  •  -
  • PARENT/GUARDIAN/EMERGENCY CONTACT INFORMATION

  •                                                                                                      

  • *Please keep in mind that a parent or an additional person must be available for contact 24 hrs/day

  • Additional Emergency Contact (NOT parent/guardian listed above):

  • INSURANCE INFORMATION

  • Please include a copy of both sides of every insurance card for your child, including hospitalization and prescription cards for private insurance, Medicaid and/or Children's Special Health Care Services.

  • HEALTH CARE PROVIDER INFORMATION:

  • BLEEDING DISORDER INFORMATION


  • TREATMENT INFORMATION


  •   Number Location
    Joint Bleeds
    Muscle Bleeds
    Other Bleeds
  • HEALTH HISTORY

    This form must be completed and signed by parent/guardian. Any changes to this information must be provided to camp health personnel prior to arrival at camp.
  •   YES NO
    Asthma
    ADD/ADHD
    Hay fever/seasonal allergy
    Heart disease/murmur
    High blood pressure
    Chest pain
    Low blood pressure
    Frequent headaches
    Seizures/epilepsy
    Head injury/concussion
    Diabetes
    Dental problems/toothache
    Abnormal menstrual history
    Bed-wetting
    Diarrhea/constipation
    Stomach problems/ulcers/colitis
    Kidney/bladder problem
    Liver disease/hepatitis
    Frequent ear infections
    Skin problems/rashes
    Bone/joint problem
    Sleep difficulties/sleepwalking
  • Required Immunization Information

  • If your child has NOT been fully immunized, you must sign a form provided by HFM.

    Immunization Waiver/Exemption Form

  • Child must bring all medications and supplies to camp. ALL MEDICATIONS MUST BE IN ORIGINAL LABELED CONTAINERS. Do not remove medications from original bottles. Medications not in original labeled containers will not be administered to child at camp.

  •   Name of Medication Dosage Times Medication is Given Purpose of Medication
    1
    2
    3
    4
    5
    6
    7
  •   Substance Reaction Management of Reaction
    1
    2
    3
    4
    5
    6
    7
  • Clear
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  • Questions? Please contact Tim Wicks at 734.544.0015 ext. 7 or at tim@hfmich.org.

  • Should be Empty: