North Canton Church of Christ - Camp Caraway Health Form

Camp Caraway Health Form 2024

Please complete this form for each child you wish to register. Every child must have a health form on file prior to attending Camp Caraway. A new health form must be submitted each year as we cannot carry over health forms from a previous year of attendance.

Camper Info

First Name

Last Name

Address 1

Address 2

Country

City

State

Zip/Postal Code

Phone Number in case of Emergency

Date of Birth

Food Allergies

Other Allergies

Medical History

Does your child carry an EPI Pen?
Yes
No

Does your child carry an inhaler?
Yes
No

May we give your child Tylenol?
Yes
No

May we give your child Motrin?
Yes
No

May we give your child Advil?
Yes
No

Medications (dosages and times). All medications must be turned in to the staff nurse or director upon arrival at camp. No medications are permitted in the cabins.

Date of last Tetanus shot?

Parent/ Guardian First Name

Parent/Guardian Last Name

Work Phone Number

Parent/Guardian First Name

Parent/Guardian Last Name

Work Phone Number

Preferred Phone Number

Guarantor Name

Place of Employment

Insurance Company name

Policy Number

Plan ID Number

Primary Care Physician

Office Phone Number

Dentist

Office Phone Number

Other Physicians?

In the event of an emergency, I authorize the camp director or his designee to secure medical or surgical treatment as recommended by a physician for the applicant's well being. The camp health director or nurse may administer any prescribed medications and treat any emergency that may arise while the applicant is at camp.

Parent Signature

Today's date

Submit

Camp Caraway Health Form 2024

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