Health Form - August Camp

Which week(s) are you attending? *

Week One
Week Two
Week Three
Week Four

First Name *

Middle

Last Name *

Email *

Email

Confirm Email

Cell Phone

Home Phone

Work Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Layout

Birthdate *

Height *

One number for feet, two numbers for inches.

Weight (pounds) *

Gender

Layout

Emergency Contact *

This person should not be someone attending camp with you.

Relationship of Emergency Contact *

Layout

Primary Emergency Phone (Day): *

Primary Emergency Phone (Cell) *

Primary Emergency Phone (Evening): *

Full Address of Emergency Contact *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Health Questionnaire

Parent or legal guardian should complete form for all children under 18 years participating in AMC program.

1. Have you experienced an asthma attack at any time in your life? *

Yes
No

Will you be carrying your inhaler on the program?

How often do you use your inhaler to treat asthma or wheezing?

2. Have you ever been diagnosed with type I or type II diabetes? *

Yes
No

Do you have poor or reduced circulation due to your diabetes?

Will you be carrying insulin or wearing an insulin pump during August Camp?

3. Have you ever experienced a serious allergic reaction, or have you ever been given a shot of epinephrine for an allergy or anaphylaxis? *

Yes
No

What are you allergic to and how does your body typically respond when exposed? (e.g. bee sting = hives)

Will you be bringing/carrying epinephrine at August Camp?

Yes
No

4. Have you ever received medical treatment for angina, a heart attack, or any type of heart disorder or disease? *

Yes
No

Are you able to exert yourself more than 30 minutes without experiencing angina (chest) pain?

5. Have you ever been diagnosed with or are you currently being treated for high blood pressure? *

Yes
No

Is your blood pressure currently under control (ie: systolic under 140 and diastolic between 60 and 100)?

6. Have you ever experienced a seizure, or are you currently being treated for any type of seizure disorder? *

Yes
No

Are you currently taking medication for your seizures?

Have you experienced a seizure within the past year?

9. ls there anything else you think we should know about your medical Background? i.e., anything that could affect your safety or ability to participate fully? *

Yes
No

Please explain here.

Food allergies. What is the type of allergy (ingested or airborne), and how severe is the reaction?

PLEASE READ CAREFULLY

Participants (or parents/guardians, if appropriate) must read and sign below.

Participant acknowledgement of accuracy and understanding. By signing this form, I am declaring that, to the best of my knowledge, I have completed the questionnaire accurately. I also understand that by knowingly filling out the form inaccurately, or by withholding pertinent information about my health, I could potentially be increasing the risk to myself or others.
Consent to accept aid. By signing this form, I am giving consent and permission for AMC staff, volunteers, representatives, or contractors to provide medical care to me or to my child, to transport me or my child to a medical facility or to seek the aid of emergency medical services as deemed appropriate. I further authorize AMC staff, volunteers, representatives, or contractors to render whatever treatment they consider necessary for my or my child’s health, and I agree to pay all costs associated with that care and transportation.After pressing SUBMIT you will be redirected to a webpage to sign this Health Questionnaire. A copy will then be emailed to you for your records.

2023 Health Form

Health Questionnaire

PLEASE READ CAREFULLY

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2023 Health Form

Health Questionnaire

PLEASE READ CAREFULLY

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