Dates of Camp Attendance Mail this form to the address below by _________ (date) Health History and Examination Form for Children, Youth and Adults Attending Camps FM 08N Suggested for resident camp use. Developed  and  approved  by American Camping Association® American Academy of Pediatrics *If for religious reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Copyright 1983 by American Camping Association, Inc. Revised 1990, 1992, 1994, 1995, 1996, 1998, 1999, 2000. Name   ____________________________________________________  Birth date ______________ Age at camp   ________ Last First Middle Home  address  ________________________________________________________________________________________ Street address City State Zip Social  security  number  of  participant _____________________________________ Gender: o Male    o Female Custodial  parent/guardian ______________________________________________ Phone   __________________________ Home  address  ________________________________________________________________________________________ (if different from above) Street address City State Zip Business  address _____________________________________________________ Phone   __________________________ Street address City State Zip Second parent or guardian or emergency contact ____________________________________________________________ Address   ____________________________________________________________ Phone   __________________________ Street address City State Zip Business  address _____________________________________________________ Phone   __________________________ If not available in an emergency, notify: Name   _______________________________________________________________________________________________ Relationship _________________________________________________________ Phone   __________________________ Address   _____________________________________________________________________________________________ Street address City State Zip Insurance Information Is the participant covered by family medical/hospital insurance? o Yes   o No If sSS="ft3">Photocopy of front and back of health insurance card must be attached to this form. Important — These boxes must be complete for attendance* For Office Use I also understand and agree to abide by any restrictions placed on my participation in camp activities. Signature of minor or adult camper/staffer ________________________________________________  Date ______________ Parent/Guardian Authorizations: This health history is correct and complete as far as I know. The person herein described has permission to engage in all camp activities except as noted. I hereby give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied for trips out of camp. Signature of parent/guardian or adult camper/staffer   __________________________________________________________ Printed Name  ______________________________________________________________________  Date ______________ The information on this form is not part of the camper or staff acceptance process, but is gathered to assist us in identifying appropriate care. Health history (first three pages) must be filled  out  by  parents/guardians  of  minors  or  by  adults themselves.  Update  required  annually.  Health  exam  (back page)  must  be  completed  by  approved  licensed  medical personnel at least every two years.