If you answered YES to any of the above, please give details:
If Camper is an Anaphylactic Please Provide a Minimum of 3 Epi Pens - Pens will be Returned at End of Session
Will camper require any treatments, injections or medications while at Chikopi? If yes, list ailment, name of drug, time and amount of dose. All medications brought to Chikopi must be in their original containers with clear directions from the Pharmacist who filled the prescription. Over the counter medications must be in their original containers with campers name clearly printed on the container.
To the best of my knowledge, the above camper is in good health. If exposed to any INFECTIOUS DISEASE within FOUR (4) weeks prior to attending Chikopi, or his medical conditions change, I will notify Chikopi in writing and submit a new health form.
In case of medical emergency, I give permission to have the camp physician/Director refer my child to hospital for treatment. I also understand that the camp physician and/or directors will try to keep my family informed of any emergency plans by phoning us either at home, work or summer place as notified above.
DATE:
Enter Full Name (e-signature):
For Chikopi Office Use OnlyDate:
Diagnosis:
Treatment:
Parents Notified? Yes: By Phone By Email Letter Date
Comments:
Initials