Camp Illahee Health Form

Step 1 of 4

Please Do Not enter "No," "None," or "N/A" in any form boxes. (Just Leave Blank) Thank you!
Contact Information
Camper's First Name*
Camper's Last Name*
Date of Birth*
Enrolled Session*
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

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Medications
Will your daughter be taking medications while at camp?*
- Yes
- No
We will continue utilizing the medication dispensing system called "Blister Packaging". We require ALL of your child’s oral medications taken on a daily basis, prescription AND over-the-counter, to be packaged and dispensed according to the guidelines. 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. Please note that we prefer medications to be dispensed at breakfast when possible.
Please list your child's medication.
Please list your child's medication.
What is the reason for taking the medication listed above?
What is the reason for taking the medication listed above?
When is the above medication administered? To select more than one time, hold down the CTRL key
When is the above medication administered? To select more than one time, hold down the CTRL key
Please indicate how this medication will be filled.
Please indicate how this medication will be filled.
If your camper will be taking a 2nd medication while at camp, please list the medication below.
If your camper will be taking a 2nd medication while at camp, please list the medication below.
What is the reason for taking the medication listed above?
What is the reason for taking the medication listed above?
When is the above medication administered? To select more than one time, hold down the CTRL key.
When is the above medication administered? To select more than one time, hold down the CTRL key.
Please indicate how this medication will be filled.
Please indicate how this medication will be filled.
If your camper will be taking a 3rd medication while at camp, please list the medication below.
If your camper will be taking a 3rd medication while at camp, please list the medication below.
What is the reason for taking the medication listed above?
What is the reason for taking the medication listed above?
When is the above medication administered? To select more than one time, hold down the CTRL key
When is the above medication administered? To select more than one time, hold down the CTRL key
Please indicate how this medication will be filled.
Please indicate how this medication will be filled.

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Insurance Information
Insurance Company
Insurance Company
Insurance Company Phone Number
Insurance Company Phone Number
Group Name
Group Name
Group Number
Group Number
Policy Number
Policy Number
Policy Holder's First Name
Policy Holder's First Name
Policy Holder's Last Name
Policy Holder's Last Name
Policy Holder's DOB
Policy Holder's DOB
Policy Holder's Relationship to Camper
Policy Holder's Relationship to Camper
Picture of Front and Back of Insurance Card (Use SmartPhone Camera)
Please upload a picture of the FRONT of your insurance card
Max. file size: 512 MB.
Please upload a picture of the BACK of your insurance card*
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
Please Type Full Name Indicating Acceptance of These Terms*

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Step 1 of 4

Contact Information

Medications

Health History

Insurance Information

Release for Treatment