Camp Health Form

Camper's Name*

First Last

Birth Date*

Age of Child on First Day of Camp*

Camp Session/Dates Attending*

Allergies*

No Known Allergies

Food

Medication

Environmental

Other

If yes, please describe allergy:

* If child has no severe allergy or asthma, please skip to "Restrictions or Adaptations" *

SEVERE ALLERGY: List each medication separate below. All must have pharmacy label!! If needed, TWO Epipens should be brought to camp. The camper must be trained in the use of the Epipen. Camp and staff will assist in administering medication if needed.

List the Severe Allergy and the Camper's Symptoms*

Check the Relevant Statement:

Camper does not need to carry medication at all times, therefore the medication shall be locked up in the office

Camper should have medication(s) with him/her at all times

ASTHMA: List each medication separately below. All must have the pharmacy label!

Check the Relevant Statement:

Camper does not need to carry medication at all times, therefore the medication shall be locked up in the office

Camper should have medication(s) with him/her at all times. Camp staff must monitor each dose.

Restrictions or Adaptations: Campers can participate:*

Without restrictions

With these restrictions/adaptations

Immunization History - Are all immunizations up to date?*

Yes

** If your camper is not fully immunized you will need to provide a certificate waiver, which can be obtained at your local health department. These forms will need to be mailed, faxed, or emailed to Dahlem prior to attendance.

Medication*

This camper does not take any medication

This camper takes medication

If your camper needs to take prescription or nonprescription medicine while at Dahlem, the camper’s parent/guardian will need to complete the boxes below. All medication must be in its original container or package, placed in a clear Zip-Loc plastic bag, and clearly labeled. The camper’s name must be printed on the label of all prescription medication. Please be sure to check that medication does not expire before the camper’s last day in our program. If possible, all medications should be given under the supervision of the parent/guardian. When this is not possible, Dahlem Camp Director may give prescribed medication as an assistance to parents/guardians.

Please List All Medications

** List must include: Name of the Medication, Reason for taking it, When it is given, Dosage, and Date the medication was started

Mental, Emotional, and Social Health

Check all that apply:

Is/has been treated for ADD/ADHD

Is/has been treated for emotional/behavioral difficulties

Is/has been treated for an eating disorder

Has seen a professional to address mental/emotional health concerns in the past 12 months

Has had significant life event that continues to affect camper

Explain any of the items checked above.

What is the best method for our camp staff to work with your camper?

Medical Insurance Information

This camper is covered by family medical/hospital insurance.

This camper is not covered by insurance

Primary Policy Holder

Relationship to Child

Health Insurance Company

Insurance Number

Physician’s Name

Physician’s Phone Number

General Release of Liability and Authorization for Treatment By submitting this health form I attest this health history is correct to the best of my knowledge and the person (camper) herein described has permission to engage in all camp activities except as noted. These completed forms may be copied for use within Dahlem camp program. In consideration for being allowed to participate in the Dahlem Conservancy’s programs, I agree to assume the risk of such activities and programs and I further agree to hold harmless the Dahlem Conservancy and its staff members conducting the activities from any and all claims, suits, losses, or related causes of action for damages including, but not limited to, such claims that may result from injury or death, accident or otherwise, during or arising in any way from the activities. I grant permission for me or my child to participate in all planned camp activities understanding that competent leadership is provided. The Dahlem Conservancy is not responsible for lost, stolen, or damaged personal articles. I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the camper mentioned above. If there is a religious objection to consenting to receipt of emergency medical or surgical treatment, the authorized person shall submit a written statement to the effect that the camper is in good health and that the person signing assumes the health responsibilities for the camper. This completed health form may be copied for use by the camp.

Camp Health Form

2025 Camper Health Form

Contact Dahlem

Visit Dahlem