Health History Campers Name* First Name Middle NameLast Name List any serious illnesses or operations your child has had. Medications: Name and Dose Does your child have any allergies?* Yes No If yes, please describe them and indicate special precautions or care needed. Does your child have history of... Frequent Ear Infections Diabetes Measles Asthma Heart Defect/Disease Bleeding/Clotting Disorder German Measles Hay Fever Convulsions/Seizures Chicken Pox Mumps Poison Ivy Insect Sting Allergy Penicillin Allergy Food Allergy Physical Handicap Other Any other problems, please list: If you checked any of these items, please describe any special emergency care instructions or other information needed by the child's care staff/provider: Chronic/Recurring Illnesses (not listed above): Any specific activities that should be discouraged? Emergency Contact Information Childs Pediatrician* Pediatrician's Phone* Insurance Company Insurance Company Phone Preferred Hospital* Dentist or Clinic Dentist Address Dentist Phone Lice Policy Camp Gan Israel has a no-not lice policy for the camp. Parents who find nits or live lice in their child's hair while their child is attending camp msut report the incident to the camp office immediately and keep their child home until they are treated. The child will need to be nit free and checked by the camp staff or an approved medical or lice expert before returning to camp. Days missed due to lice will not be refunded. Photo Release I hereby grant permission to Camp Gan Israel to use photographs and/or video of my child to be used in publications, news releases, online, and in other communications related to the mission of Camp Gan Israel. Photo Release? (None Selected) Photo Release provided Photo Release NOT provided Parent Consent Information I hereby give consent for emergency medical treatment, to be used only is I cannot be reached immediately. I hereby give permission for my child to participate in field trips during operating hours. Details will be given to me in advance. I hereby give me consent for my child (listed above) to receive prescribed medications during camp hours when regular attendance at camp would be impossible without the medication. Signing below will indicate that I have released all persons affiliated with Camp Gan Israel from all liability for damages resulting directly or indirectly from this authorization. (Prescription medications section of this form must be filled out completely and a physician's statement must accompany medication). By signing my electronic signature below I am giving permission for all the items above. Parent Consent E-signature* Additional Comments This page uses 128 bit SSL encryption to keep your data secure.
