Camp Illahee Health Form - Camp Illahee Girls Summer Camp

Contact Information

Camper's First Name*

Camper's Last Name*

Date of Birth*

Enrolled Session*

Three-Week (June 8 - June 27)
Four-Week (June 29 - July 25)
Mini 1 (June 29 - July 11)
Mini 2 (July 13 - July 25)
Two-Week (July 27 - August 8)
Junior (August 10 - August 15)

1st Parent/Guardian First Name*

1st Parent/Guardian Last Name*

1st Parent/Guardian Cell*

Emergency Text

The cell phone above can receive a text message in case of emergency.

2nd Parent/Guardian First Name*

2nd Parent/Guardian Last Name*

2nd Parent/Guardian Cell*

Emergency Contact's First Name (If unable to reach parent/guardian )*

Emergency Contact's Last Name*

Relation to Camper*

Emergency Contact's Cell Phone*

Phone number for International campers

Camper Doctor's First Name*

Camper Doctor's Last Name*

Doctor's Phone*

Medications

Will your daughter be taking medications while at camp?*

Yes
No

All daily medication must arrive at camp in Blister Packaging, filled by a licensed pharmacist along with a prescription, and labeled with the dosage instructions and name of the prescribing physician. This includes prescription medication, over the counter medications, vitamins, supplements, melatonin, etc. that your child takes on a daily basis. Campers are not allowed to bring products containing CBD or CBD oil to camp. Please note that we prefer medications to be dispensed at breakfast when possible. Prescription medications taken "as needed" (such as migraine medicine) do not require Blister packaging but must be in the original packaging with an original pharmacy label, including the dosage instructions and name of the prescribing physician. Our camp infirmary is fully stocked with over the counter medication, please do NOT bring over the counter medications from home for "as needed" use. Please review our Parent Handbook, which contains our full medication policy.

Please list your child's medication(s).*

List the reason(s) your child is taking the medication(s) listed above?*

Please indicate how this medication will be filled.*

Health History

Does your child have any allergies?*

Yes
No

Please name the allergen below.*

What is the severity of this allergy?*

Additional Allergy

My child has an additional allergy

Please name the second allergen below.*

What is the severity of this allergy?*

Additional Allergy

My child has an additional allergy

Please name the third allergen below.*

What is the severity of this allergy?*

Please select any dietary restrictions below:

Gluten Free
Dairy Free
Vegetarian
Vegan
Other

Please provide additional details*

Please check all that apply to your camper. Scroll down to view entire list.

Please explain any items selected.*

Has your child ever received counseling or been treated for anxiety, depression, eating disorder, self-harm, bullying, or another mental health related concern?*

Yes
No

If yes, please elaborate and describe any past or current therapy she is receiving.*

Insurance Information

Policy Holder's First Name*

Policy Holder's Last Name*

Policy Holder's DOB*

Policy Holder's Relationship to Camper*

Picture of Front of Insurance Card (Use SmartPhone Camera)*

Please upload a picture of the FRONT of your insurance card

Max. file size: 512 MB.

Picture of Back of Insurance Card (Use SmartPhone Camera)*

Please upload a picture of the BACK of your insurance card

Max. file size: 512 MB.

Release for Treatment

This health history is complete as far as I know. In the event that I cannot be reached in an emergency, I hereby give permission to the physician(s) selected by the camp director to hospitalize, secure treatment for, and to order injection, anesthesia, or surgery for my child named above.

I authorize the release of any records necessary for treatment, referral, billing, or insurance purposes. I hereby give permission for the nursing and medical staff to administer prescription and non-prescription medication brought from home, stocked in the health center, or prescribed while at camp.

I understand that any incidental charges, including medical bills for any accident, illness, or medications will be my responsibility. Camp Illahee, its medical providers or pharmacists may not file insurance information (we will provide receipts so that you can file). I understand that all accounts with camp and its medical providers must be settled within a month after the close of my daughter’s session.

It is the responsibility of parents/guardians to become familiar with all of the activities and programs offered by Camp Illahee as described in literature, online videos, and in our parent handbook. I understand that my child’s participation in Camp Illahee and any activity is entirely voluntary, and that it is my responsibility to communicate to the camp directors if there are any restrictions to the normal activity program for my camper.

I further recognize that there are hazards and dangers inherent in camp events and programs, and Camp Illahee cannot guarantee that the participants, equipment, premises and/or activities will be free of hazards, accidents and/or injuries. I have further instructed my child in the importance of knowing and abiding by the camp’s rules, regulations, and procedures for the safety of camp participants.

By typing my full name in the signature box below I acknowledge that I have carefully read and agree to the above terms and conditions, that all of the information I have provided to Camp Illahee is accurate, that I am electronically signing this instrument on my own behalf and as parent or guardian of Participant, and that I am willing to engage in this transaction by electronic means.

Please use your browser print function to print a copy of this for your records before submitting.

Please Check Only One*

I agree to the above Terms and Conditions
I DO NOT agree to the above Terms and Conditions

If you do not agree with the above Terms and Conditions, you must call our office to discuss (828)883-2181.

Please Type Full Name Indicating Acceptance of These Terms*