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Crossways Health History Form
Year: ___________
BRING THIS FORM TO CAMP. DO NOT MAIL IT AHEAD OF TIME.
NAME OF CAMPER ____________________________________________________________________________________
Grade_______ Birthdate____________ Age_______  Male  Female Camp Season:  Summer Camp  Retreat Season
(If school year is not in session, enter grade completed in previous school year.) Site:  Waypost  Pine Lake  Imago Dei Village
Address ___________________________________________________ Camp Dates: ____________________________
City, State & Zip _____________________________________________ Program: ________________________________
Camper Church, City __________________________________________ A health form must be on file for every camper for EACH session
regardless of past participation at camp.
Parent/Guardian(s) ___________________________________________ Wisconsin State Health Code - State law requires that this form
(completed and signed) be on file at the camp in order for the participant
Home Phone _______________________________________________ to attend a residential Crossways Camping Ministries program. Cell Phone (include name & number) ________________________________________________________________ Emergency Contact & Relationship _______________________________ Emergency Contact Phone _________________________ (For campers under 18, list alternate emergency contact if parent/guardian(s) are unavailable.) HEALTH INSURANCE
Please attach a copy of your insurance card (both sides) to this form.
Insurance Company _______________________________________ Policy No _________________Phone ____________________ Health Care Provider’s Name ________________________________ Phone ____________________________________________ Address ____________________________________________________________________________________________________ Crossways carries SECONDARY insurance only. You are responsible for all PRIMARY coverage.
HEALTH HISTORY
1. Check if camper has been subject to medical treatment for any of the following:  Diabetes ______________________________________________________________________________________________  Allergies ______________________________________________________________________________________________  Asthma _______________________________________________________________________________________________ Please explain above: _____________________________________________________________________________________ _____________________________________________________________________________________ Give dates of immunizations: MMR ____________ Tetanus + Pertussis Tdap ____________ OR Tetanus Td ____________ Chicken Pox ____________ Hepatitis B ____________ 2. Current medications: Give name, dose, schedule (medication MUST be brought in ORIGINAL labeled prescription bottle). _______ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 3. Please explain conditions requiring medication or other conditions requiring special care: ________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Page 1 of 2
Crossways Health History Form
Year: ___________
BRING THIS FORM TO CAMP. DO NOT MAIL IT AHEAD OF TIME.

NAME OF CAMPER ____________________________________________________________________________________
4. Check if camper is allergic to the following, please describe reaction:  Penicillin _____________________________________________________________________________________________  Other Drugs __________________________________________________________________________________________  Bee Stings ___________________________________________________________________________________________  Foods _______________________________________________________________________________________________  Other _______________________________________________________________________________________________ 5. Please indicate any restrictions on physical activities or any concerns you may have regarding the camper’s stay at camp: _______ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Over the Counter Medication: The following are medications that we keep on hand at camp. Do not bring any of the
medications listed below with you. Please place a check by all of the medications that you are comfortable with us giving your child. All medications are given according to instructions found on the medication packaging and per consulting & under physician’s protocol.
Is the camper subject to homesickness? If yes, provide suggestions on how to handle circumstances: ______________ _______________________________________________________________________________________________ For cam _______________________________________________________________________________________________
REQUIRED AUTHORIZATION FOR ALL PARTICIPANTS (Youth and Adults)
I hereby give permission for __________________________ to take part in all camp activities, including offsite activities under supervision, and I agree that the camp, or its personnel, will not be held responsible for accidents or personal injury arising therefrom. In the case of a medical emergency, I understand that every effort will be made to contact the parents or guardians of the camper. In the event I cannot be reached I hereby give permission to the medical examiner selected by the Crossways staff to hospitalize, to secure proper treatment for, to order an injection, anesthesia, or surgery for my child as named on this form. I understand that Crossways Camping Ministries does not provide medical insurance. I further authorize Crossways Camping Ministries to use photos, videos or other likeness of the above named for Crossways publicity
with no identifying information posted. Please initial here if you DO NOT authorize this use: ____________

SIGNATURE ________________________________________________ DATE _____________
For campers under the age of 18, parent/legal guardian signature required.
Name & Address Printed ________________________________________________________________
Page 2 of 2

Source: http://www.crosswayscamps.org/pdf_files/Health%20Form%20Crossways.pdf