Covenant Christian Reformed Church
CROSSROADS
HEALTH FORM
It is very important that you fill out this form as completely as you can.

Thank You!
Begin Health Form!
 
Camper Name: *

 
Address: *

 
City: *

 
State: *

 
Zip: *

 
What is {{answer_iSoRxjArPD6X}}'s date of birth? *

 
What age will {{answer_iSoRxjArPD6X}} be at the time of camp? *

 
In the next section we will be asking you for your EMERGENCY CONTACT INFORMATION:

 
Primary Contact: *

 
Relationship to Camper *

 
Phone Number: *

 
Secondary Contact:

 
Relationship to Camper:

 
Phone Number:

 
Thank you! This next section will require your Medical Insurance Information

If you have medical insurance, your carrier will be billed for medical charges in case of illness or injury while your child is at Crossroads Camp.
 
Insurance company:

 
Policy Number:

 
Group Number:

 
Whose Name is the policy in?

 
Family Doctor:

 
What town is {{answer_aI1jwkB9r3cv}} in?

 
{{answer_aI1jwkB9r3cv}}'s Phone number:

 
Health History

Please list below any pre-existing or present medical conditions, or activity restrictions of which camp staff should be aware:
 
Please list the name and dosage of any medication the camper must take:

 
Does your child have a severe allergy, and require special attention for it?

     
 
Allergic Reaction Plan

 
What is the allergy to?

 
How severe is the allergy when exposed?

 
Administer Medicine?

Provided by the parents to the camp staff

 
Medication/Dose/Route

 
Is there another allergy you'd like us to be aware of?

     
 
Allergic Reaction Plan 2

 
What is the allergy to?

 
How severe is the allergy when exposed?

 
Administer Medicine?

Provided by the parents to the camp staff

 
Medication/Dose/Route

 
Date of last Tetanus Shot:

 
Please share any concerns you may have:

 
Will you be registering anyone else?

     
Please complete additional health forms for any more campers you've registered!
Additional Health Forms!