Health Registration Form Camper/Worker Name First Name Last Name Parent or Guardian (if applicable) First Name Last Name Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Are you (camper) under the guardianship of the court, government agency or foster ? Yes No Please check if you have had a history of any of the following, (any medical history?) Asthma Heart trouble Sinus trouble Ear trouble Bed wetting Diabetes Frequent colds Allergies Athletes foot Upset stomach Kidney trouble Sleepwalking Epilepsy Emotional difficulty If Allergies are checked, please specify to what Please List Any Medications Authorization to use these over-the-counter meds: Ear Drops Eye Drops Ibuprofen Tylenol Antacid Dietary restrictions: Activities that should be restricted Family Doctor Name & Phone Number In case of Emergency, I understand that the people listed above will be notified if possible and I hereby give permission to the Physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child (or myself) as named above. NOTE: Laclede Baptist Camp insurance is a secondary insurance. The camper’s insurance is primary insurance. Name of camper’s insurance Phone Number / Policy Number / Group Number Thank you!