Camp Participant Vaccination Assessment Form
Please complete this form to assess your vaccination status and related health information for camp participation.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you received all age-appropriate routine vaccinations?
*
Yes
No
Not Sure
Please indicate your vaccination status for the following vaccines.
*
Rows
Up to Date
Not Up to Date
Not Sure
Measles, Mumps, Rubella (MMR)
1
2
3
Tetanus, Diphtheria, Pertussis (Tdap)
4
5
6
Polio
7
8
9
Varicella (Chickenpox)
10
11
12
Hepatitis B
13
14
15
COVID-19
16
17
18
Have you experienced any adverse reactions to vaccines in the past?
*
No
Yes
Not Sure
If yes, please describe the adverse reaction(s):
Do you have any known allergies (including to vaccines or vaccine components)?
*
No
Yes
If yes, please list your allergies:
Have you had any serious illnesses or hospitalizations in the past year?
*
No
Yes
How would you rate your overall current health?
*
1
2
3
4
5
Submit Assessment
Should be Empty: