Health History Record

for the Michigan Department of Licensing and Regulatory Affairs

Dear Authorized Person:

The following information is requested so that the camp can better meet the physical, intellectual, and emotional needs of the camper or minor staff. Fill out the information requested. “Authorized person” means a parent, guardian, or adult camper’s designee.

Parent/Guardian's Name

Parent/Guardian's Email

Parent/Guardian's Phone Number

Minor Child's First name

Minor Child's Last name

Gender

Male

Female

Date of Birth

Month

Day

Year

Child's Age

Minor Child's Address

Country/Region

Address

City

Zip / Postal code

Please explain any problem areas identified above including any current infectious diseases

If female has she been told about menstruation (answer if appropriate)

Yes

No

Has she menstruated (answer if appropriate)

Yes

No

Operations or Injuries

Explain Any Special Health, Behavioral or Emotional Consideration(s)

Please list any medication needed or used (Including Psychiatric).

Special conditions to be watched for such as ALLERGY (Reactions to food, Penicillin, or other drugs), Bedwetting, Fainting, Sleep Walking, etc.

IMMUNIZATIONS: Are the minor child (age 5 and older) immunizations up to date?

Yes

No

For children under age five attending camp attach a certificate of immunization record and status of the minor child’s immunizations or provide a written religious or other exemption waiver signed by a physician.

Should the camper’s activity be restricted because of any physical limitation or illness?

No

Yes

If yes, explain degree of restriction:

Medical Emergency Care Authorization: I hereby give permission to the children’s camp to secure emergency medical and surgical treatment and to provide routine, nonsurgical medical care, for the minor child named above, while attending camp. By signing below, I authorize care.

For Religious Exemption: I object to consent to receipt of emergency medical or surgical treatment, by signing below I attest that my child is in good health, and I assume the health responsibility for my child.

Authorized Person's Name Filling Out this Form

Is the Authorized Person's address the same as the child listed above?

Yes, we live at the same address

No, mine is different

Today's Date

Signature

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IMPORTANT NOTE: This form must be on file for EACH child attending an independent program at Jubilee without their parent/guardian accompanying them. If you have another child attending, please submit an additional form on their behalf too. Thank you!

Health History Record

Health History Record

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