Camper Information and Health Inventory Form

Camper Information and Health Inventory Form

This form must be filled out completely by a parent or guardian.

Provide detailed information to help us meet your child’s needs. All information given is confidential and held for staff use only.

This form must be completed and returned by June 2, 2025.

General Camper Information

First Name*

MI

Last Name*

Date of Birth*

Age*

Sex*

Tshirt Size*

Camper / Guardian Email Address*

Legal Parent / Guardian Information

Parent / Guardian Full Name(s)*

Cell Phone*

Phone

Home Phone

Phone

Other Phone

Phone

Mailing Address*

City*

State*

Zip Code*

Email Address*

Other Emergency Numbers

Name*

Relationship to Camper*

Phone*

Phone

Camper Lives with (select one)

Both Parents

Father

Mother

Other

Please note who the camper lives with below

Medical Information

Pediatric Cardiologist Name*

Pediatric Cardiologist Phone Number*

Phone

Family Physician Name*

Family Physician Phone*

Phone

Name of Heart Problem(s)*

Immunization and Exposure History

Are your child's Immunizations up to date?*

Yes

No

Has camper been exposed to chicken pox or any other communicable disease in the past 1-3 months?*

Yes

No

Please explain their exposed to the communicable disease*

Medications

You will need to send in a copy of your child's insurance card (This can be attached at the bottom of this form)

Please list your campers medications, dosage and times of day given*

Example:

Tylenol / 1 capsule / Every 8 hours

Name of Pharmacy*

Pharmacy Phone Number*

Phone

Allergies

Does the camper have allergies to any medications, foods, or other things?*

Yes

No

Please list allergies below and what happens if the camper is exposed*

Is he/she required to carry an EPI Pen?*

Yes

No

Other General Information

Does your child need assistance with any normal daily activities?*

Yes

No

Please explain the assistance needed*

List any other chronic or recurring illnesses that we should be aware of*

If none, please note "N/A"

Has your child ever had seizures or neurological disorders?*

Yes

No

Please describe this condition including how often and when was the last occurrence:*

If your child is being followed by a Neurologist, a letter of clearance is needed to attend camp

Has your child been under the care of or been counseled by a School Counselor, Social Worker, Psychiatrist, or Psychologist at any time?*

Yes

No

Please explain*

Use the space below to provide any additional information about your child’s behavior or physical, emotional, or mental health the camp should know about (i.e. recent move, recent death, serious fears, etc.)*

Is your child on a special diet for health or religious reasons?*

Yes

No

Please explain your child's special diet:*

Does your child participate in any sports?*

Yes

No

What kind of sports do they participate in?*

Activity Level (Select One)*

**If you choose “Not Active”, Upbeat Hearts Camp may not be appropriate for your child.

Not Active- Does not like to walk/run or go outdoors much

Somewhat Active- Likes indoors, but does walk/run or play for less than 30 mins per day at least 3 times a week

Active- Walks/runs/plays outside most of the time or at least 30 mins per day 3x’s a week

Very Active- Plays sports or walks/runs/plays 30 mins or more each day

Please attach any documentation here

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