Joy of Living Camp

2017 Summer Camp Health Form

 Page 1 - Personal Information and Authorization

CAMPER INFORMATION

Camper Name *
First Name
Middle
Last Name
The "Camper Address" must be the street address at which the camper resides.
Camper Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Camper Date of Birth (mm/dd/yyyy)*
Camper Gender *

PARENT/GUARDIAN AND EMERGENCY CONTACT INFORMATION

Parent/Guardian with legal custody to be                               contacted in case of illness or injury:

Name *
First Name
Middle
Last Name
Relationship to Camper *
Cell Phone*
Alternate Phone*
E-mail Address*

Second Parent/Guardian or                                                         other emergency contact:

Name: *
First Name
Middle
Last Name
Relationship to Camper *
Cell Phone Number*
Alternate Phone*
E-mail Address*

Optional additional contact in event parent(s)/legal                 guardian(s) cannot be reached:

Name
First Name
Middle
Last Name
Relationship to Camper
Cell Phone
Alternate Phone
E-mail Address

MEDICAL INSURANCE INFORMATION

This camper is covered by family medical/hospital insurance *
Please provide Joy of Living Camp with a copy of both sides of your child's health insurance card, if appropriate. There are two ways to furnish this information to Joy of Living Camp: EMAIL: Scan both sides of the card and e-mail as an attachment to registration@thejoyofliving.org, or MAIL: Copy both sides of the card and mail to Joy of Living Camp, PO Box 338, Brinkhaven, OH 43006
Insurance Company Name
Insurance Policy Number
Insurance Subscriber
First Name
Middle
Last Name
Insurance Company Phone Number

PARENT/GUARDIAN AUTHORIZATION FOR HEALTHCARE

The health history is correct and accurately reflects the health status of the camper to whom it pertains. The camper named herein has permission to participate in all camp activities, except as I have noted in writing. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information of this form will be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
By entering my name in the space provided below, and by submitting this form to Joy of Living Camp, and and stating that I am authorized to grant the permissions contained herein.
Authorizing Name *
First Name
Middle
Last Name
Date*
Relationship to Camper *