Highland Park Youth Camp - Medical Form

Please complete this medical form and click submit.  The registration process is not complete until this form and the Grand View Hospital Emergency Room Form are submitted.  We will ask you to sign both forms upon check-in at the start of camp.

Camper's Name *
Camper's Name
Camper's Birthdate *
Camper's Birthdate
Parent/Guardian #1
Parent/Guardian #1 Name *
Parent/Guardian #1 Name
Address *
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Parent/Guardian #2
Parent/Guardian #2 Name
Parent/Guardian #2 Name
Address
Address
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Alternate Emergency Contact
Alternate Emergency Contact Name *
Alternate Emergency Contact Name
Phone Number *
Phone Number
Insurance Information
Medical Information
Date of Last Physical
Date of Last Physical
(if applicable)
Check those that apply, and explain as necessary:
i. e. first time away from home, etc.
Parent Authorization: This health history and other information requested are accurate to the best of my knowledge. The child herein described has permission to engage in all prescribed camp activities, except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp Health Director to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child. I have read and fully understand this statement.
Parent/Guardian Name *
Parent/Guardian Name
Please enter your name. We will later ask you to sign this form upon Check-in.
Today's Date
Today's Date