Health Form

Camper's Name *

First

Last

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Birth Date *

Gender *

Parent/Guardian Name: *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

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Cell Phone *

Home Phone

In case of an emergency and parent/guardian is unreachable, please notify:

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Name: *

Relationship *

Phone *

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Name:

Relationship

Phone

Allergies and Dietary Restrictions

Does your camper require an EpiPen? *

Yes
No

Please provide details about your camper’s anaphylaxis, including the date and description of the reaction:

Does your camper have any allergies? *

Yes
No

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Allergic reaction details, date and descriptions:

Does your camper have any dietary restrictions? *

Yes
No

Please provide details about your camper’s dietary restrictions:

Medications and Treatments

Will your camper be taking any medications while at camp? *

Yes
No

Please explain the reason for the medication and any notes on giving this medication to your camper in the spaces below.

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Will your camper require any treatments while at camp? *

Yes
No

Please explain what treatment(s), including the frequency.

Does your camper regularly take any medications that will not be taken at camp? *

Yes
No

Explain what medications your camper takes regularly and why they are taken.

Immunizations:

If you have a copy of your immunization card, you can upload it here.

Immunization Card Upload

Click or drag a file to this area to upload.

If you do not have your immunization card please list the date or confirm your camper’s most recent vaccination (if any) or booster is up to date for the following:

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Tuberculosis (TB)

Chicken Pox (Varicella)

Diphtheria, Pertussis,

Tetanus (DPT)

Hemophilic Influenza B

Hepatitis B

Measles

Rubella

COVID

If your camper has not been fully immunized, please explain:

Over the Counter Medications:

The following over the counter medications may be given to your camper while at camp. Check all that apply. If there is a preferred or needed name brand, please purchase and check-in as medicine.

Health History

Please check if your camper has experienced, or is currently experiencing, any of the following conditions?

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Has your camper had any operations? *

Yes
No

Has your camper ever been hospitalized or had a serious injury? *

Yes
No

Has your camper been exposed to any communicable diseases within the last 3 months? *

Yes
No

Does your camper have any restrictions on activities? *

Yes
No

Will your camper require any special assistance while at camp? *

Yes
No

If you answered “yes” to any of the above questions, please describe further here. Fully explain any condition your camper is currently experiencing and how staff can better assist. Please list any other medical information the camp should have about your camper.

Health Insurance, Physician & Dentist/Orthodontist Information:

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Name of Policy Holder *

First

Last

Phone *

Employer Name (if insured through company):

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Health Insurance

Policy#

Group #

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Physician Name:

Phone:

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Dentist Name:

Phone:

Authorization and Release: *a signature is required from a child’s parent or legal guardian

General Release for all campers:
I hereby give permission for the camper and/or myself, as named above, to participate in all camp scheduled activities including sport challenges, zip-lines, swimming, kayaking, and off-site field trips, except as noted. I have read the registration, payment, refund and cancellation information, and agree to the provisions as stated. I have read and agree to the CNJ Privacy Policies found at campnewjourney.org/privacy including permission to use photos of the camper and/or myself in CNJ promotions. The named camper will follow the camp rules and direction of camp staff.

Youth Camper Medical Release:
I hereby give permission for the camper, previously named, to receive the over-the-counter and prescribed medications as indicated at the direction and under the supervision of designated Camp Health Center staff. I hereby give permission to the medical personnel selected by the camp director to provide routine health care; order x-rays, routine tests and treatment; to release any records necessary for insurance purposes; and to arrange necessary transportation for my child. In the event I am unreachable in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for child as named above. This completed form may be photocopied for trips out of camp.

I hereby certify that, to the best of my knowledge, the provided information is true and accurate

Choice 1

Signature *

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Printed Name *

Date *