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

Last Name

Date of Birth

mm/dd/yyyy

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

Camper Lives with (select one)

Both Parents

Father

Mother

Other

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

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

Yes

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

Is he/she required to carry an EPI Pen?

Yes

Other General Information

Does your child need assistance with any normal daily activities?

Yes

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

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

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

Does your child participate in any sports?

Yes

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 a copy of insurance (front and back) and picture of your camper here

Drop your files here

Send me a copy of my responses

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