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Camper's Health Record
Please print one for each child.

Camper Name ______________________________________________________________
Age_________	Height ________	Weight________
In Case of Emergency Notify___________________________________
Phone (____) _________		Relationship to Camper____________
Camper's Physician___________		Phone (___) _____________

Allergic: Drugs __	Plants __	Food __	Bee Stings __
Others? Please Explain:__________________________________________
Has camper had Chicken Pox?		Yes ___	No ___
Does Camper have any known Physical limitations or abnormalities?
__________________________________________________________________________
Last Tetanus Immunization date: _________________
Date of last Booster: __________________
If doctor advises, can camper take tetanus immunization? Yes___ No___
Has your child had head lice in the last six months? Yes___ No___
Is camper currently taking any medications? Yes___ No___
If yes, please complete the following:
Name of drug: ___________________		Name of drug: ______________________
Dosage: _____________________		Dosage: ___________________________
Recommended times for medication:
___________________________________________________________________________
Medical instructions: _________________________________________________________
___________________________________________________________________________
Medical History (please indicate Y for “yes” or N for “no”)
___Asthma	___ Diabetes	___ Heart Trouble	___ Sinusitis
___ Athlete's foot	___ Ear Aches	___ Kidney Trouble	___ Sleep Walking
___ Bronchitis	___ Fainting	___ Lung Trouble	___ Stomach Upsets
___ Convulsions	___ Freq. Sore Throat	___ Rheumatic Fever

Please notify the camp if this child was exposed to any communicable disease during the three weeks prior to camp attendance.

Camp Agreement

We are in favor of this person attending camp and participating in all activities unless we specify otherwise. As parents or legal guardians, we accept the conditions stated, including the release of the Ellijay Wildlife Rehabilitation Sanctuary & Camp Wildlife management from liability in case of accident or illness. We do support, and applicant agrees to abide by, all camp regulations and policies. We also understand that due to the nature of the summer camp budget, no refunds will be given if the camper is required to leave camp for any reason. We understand campers may be photographed for use by news media, publications or promotional materials, and we consent for E.W.R.S. to use all photographs made. In case of emergency, we hereby give permission to the physician selected by the camp directors to hospitalize, secure proper treatment for, and to order injection, anesthesia and/or surgery as deemed necessary for the camper. In accordance with E.W.R.S. policies, we have completed and submitted the Camper’s Health Record form.

X __________________________________________________________________
Signature of Parent or Guardian Date

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