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First, Middle, and Last
Please submit the completed form by May 1st to WeHaKee Camp for Girls Administrative Office. Please follow the instructions below.
Parent / guardian with legal custody to be contacted in case of illness or injury:
Second parent / guardian or other emergency contact:
Additional contact in event parent(s) / guardian(s) cannot be reached:
You are required to submit a copy of your health insurance card (copy both sides of the card so information is readable!). Use the file upload field to send us a copy of your insurance card. Please fill out the rest of the medical information regarding your coverage information.
The maximum file size to upload is 7MB. If your file is larger, please e-mail it to [email protected]. Files that are accepted include: jpg, jpeg, png, and pdf.
*If NO to any of these vaccinations, please contact our Administrative Office as soon as possible.
You must provide official documentation of your child’s immunization history. This documentation can be acquired from your family healthcare provider of from your local or state government. This form is not complete and your child may not be admitted to camp without this official documentation. Because our camp community has the potential for the presence of communicable diseases, all program participants are REQUIRED to be vaccinated in accordance with the American Academy of Pediatrics’ most recent Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger (https://tinyurl.com/y7bkysdf). Only bona fide medical exemptions to our immunization requirement will be considered.
Official written documentation signed by an appropriately licensed medical professional is required for exemption consideration.
Please list all known.
Please be as precise as possible. For example: "If my daughter eats anything with nuts, she gets hives."
“Medication” is any substance a person takes to maintain and/or improve their health - this includes vitamins, supplements, and homeopathics. All medication (prescription and non-prescription, including vitamins, supplements, and homeopathics) must be turned into the health director upon arrival at WeHaKee Camp for Girls.
ALL PRESCRIPTION MEDICATIONS MUST BE IN ORIGINAL PHARMACY CONTAINER WITH LABELS which shows the camper’s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.
Please do not send non-prescription medications with your child unless they are needed on a daily basis. If you send non-prescription medication with your child, IT MUST BE IN ITS ORIGINAL CONTAINER WITH ALL LABELS ATTACHED.
Please be as precise as possible. For example: "My daughter needs to always have something with sugar with her to keep her blood sugar balanced."
Check “Yes” or “No” for each statement. Explain “Yes” answers below.
I confirm that I am the parent/legal guardian of the child listed on this Health History form and as such I have current legal custody of said child. This health history is complete and thorough and accurately reflects the health status of the camper to whom it pertains. I attest that all of my child’s immunizations are up to date in accordance with the American Academy of Pediatrics’ most recent Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for and order injection, anesthesia, or surgery for this child. In the event that my child is hospitalized for an extended period (more than 1 night), I understand that I am responsible for making immediate arrangements to travel to their hospital location to provide supervision, personal support, transportation, etc. I understand the information on this form may be shared on a “need to know” basis with camp staff. I give permission to photocopy this form. In addition, WeHaKee Camp for Girls has my permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.
