Older Camper Weekend Health Form

Camp Onas

609 Geigel Hill Road, Ottsville, PA 18942

Please return with registration. 

Health History
Name: Birth Date:
Home Address: Age at camp:
City:                                          State:            Zip: Gender: ____ Male    ____ Female
Home phone:
Parent Name:  Phone # where you can be reached in an emergency: 
Emergency contact:  Emergency contact phone #:
Insurance Information:
Plan name: Group #:
Name of insured: Relationship to participant:

IMPORTANT: PARENT MUST COMPLETE AND SIGN.
This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted.

Authorization for Treatment: I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment, and necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for my child as named above. 
Signature of parent/guardian: 
Date:
Allergies: List all known allergies. Describe reaction and management.
   
   
   
Date of last Tetanus vaccination:
 

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