Bethany x Rainbow Trail DayCamp/VBS

Health History Questionnaire

*To be completed by a parent/guardian

Child or Volunteer First Name

Child or Volunteer Last Name

Birthdate

Gender

Parent/Guardian First Name

Parent/Guardian Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Do you carry medical/hospital insurance?

Yes

No

Carrier

Group/Policy Number

Name of Physician

Physician Phone Number

Please provide the most recent date for the following immunizations for the child/volunteer:

Tetanus Immunization

DPT Immunization

Polio Immunization

Measles (MMR) Immunization

Check any of the following diseases which have occured

Chicken Pox

Measles

German Measles

Mumps

Date of Diseases

Operations/Serious Injuries

Date of Operation/Injury

Activity Level

Will your child need to take medication during Day Camp?

Yes

No

Medication Instructions

Will medication need to be collected by Day Camp Coordinator?

Yes

No

*Any medication collected needs to be in original container

PHOTO RELEASE

“I am interested in the policies and programs of Rainbow Trail Lutheran Camp and give my child permission to participate in all activities. I agree that Rainbow Trail Lutheran Camp and Bethany Lutheran Church will not be held responsible for accidents or persons injured arising therefrom. I also understand my photo or my child’s photo may be taken. I waive the right to inspect or approve the photo(s) if used in camp promotional literature.”

Single Choice

YES, I authorize Bethany Lutheran Church to take photos of my child/volunteer.

NO, I do not authorize Bethany Lutheran Church to take photos of my child/volunteer.

My child has permission to participate in all camp activities, except as noted. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests and treatment for the health of my child. In the event, I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize or secure proper treatment (including surgery, injection, and/or anesthesia) for my child as named above. I have chosen to authorize or not authorize Bethany Lutheran Church to take photographs of my child.

Signature