Medical Information & ReleasePlease enable JavaScript in your browser to complete this form. - Step 1 of 9Camper's Name *Camper's Sex *Please Choose OneFemaleMaleTrans/IntersexIs your child covered by a hospitalization/medical care policy? *Please Choose OneYesNoInsurance Company NamePolicy NumberNextHigh Blood Pressure *YesNoHeart Disease *YesNoHeart Murmur *YesNoIrregular Heartbeat *YesNoTuberculosis *YesNoHepatitis *YesNoSeizure Disorder *YesNoBleeding Disorder *YesNoAsthma *YesNoDiabetes *YesNoHypoglycemia *YesNoAnorexia *YesNoBulimia *YesNoCancer *YesNoSkin Problems *YesNoCirculation Problems *YesNoHead Injury *YesNoHeadaches *YesNoStomach Ulcers *YesNoIntestinal Problems *YesNoHeatstroke *YesNoBladder Infections *YesNoKidney Problems *YesNoThyroid Problems *YesNoAllergy to Iodine *YesNoHearing Impairment *YesNoVision Impairment *YesNoSleep Walking *YesNoBroken Bones *YesNoNeck Problems *YesNoBack Problems *YesNoArm Problems *YesNoShoulder Problems *YesNoKnee Problems *YesNoAnkle Problems *YesNoFoot Problems *YesNoCurrently Pregnant *YesNoSpecial Diet *YesNoMedical Equipment/Device *YesNoSurgery *YesNoColdsores *YesNoSexually Transmitted Disease *YesNoChronic/Frequent Illness *YesNoPMS or Menstruation Problems *YesNoRecurring Diarrhea or Constipation *YesNoOther *YesNoIf you answered YES to any of the listed conditions/symptoms, please explain below. Include specific information about how long the condition lasted, dates of occurrence, and treatment. How does this condition affect your child’s ability to participate in camp activities? *Are there any other relevant medical conditions or medical information Camp Koinonia staff should know, including but not limited to: physical or psychological limitations, recent injuries, recent or routine medical treatment(s), therapy or personal counseling, etc. *PreviousNextDoes your child have any psychological or mental health issues? Please describe. *Does your child have any history of trauma? Please describe the history and any ways in which we should be sensitive. *Does your child have any emotional or behavioral problems? Please describe. *Does your child have any issues related to sleep or bedtime that we should be aware of? Please describe. *PreviousNextDoes your child have, or has he/she had any of the following developmental conditions?Mark every question either Yes or NoLearning Difference *YesNoCognitive Difference *YesNoPhysical Difference *YesNoOther Developmental Difference *YesNoIf you answered yes to any of the above, please describe.Does your child exhibit any other diagnosed or recognized issues? Please describe. *Does your child have any other special needs that haven't been covered on this form? Please describe *PreviousNextHas your child been stung by a bee, hornet, wasp, or yellow jacket before? *YesNoIs your child allergic to any insect bite or sting? *YesNoIf yes, please describe the reaction:List all allergies, including reaction and medication required: *PreviousNextCamp Koinonia staff may administer over-the-counter medicine to my child, if necessary. *YesNoList Any Restrictions:List any hospital or emergency department visits in the last two yearsInclude the date, reason, and length of stayNextDietary needs at campCamp Koinonia strives to make our summer camp enjoyable and possible for all campers, regardless of any dietary restriction they may have. Our camp kitchen is able to accommodate most restrictions and sensitivities. However, if a camper has a severe condition that requires them to consume a diet entirely composed of highly specialized foods, it may be necessary for them to bring food with them to camp. We will contact you to discuss your child's needs.Medical Dietary Restrictions: *Please list any restricted food(s) to which your child has an allergy or sensitivity.Describe your child's reaction to these foods: *Non-Medical Dietary Restrictions *If your child keeps a special diet for ethical or religious reasons, please list restricted food(s).PreviousNextNOTICE: The following is required. Participants will not be accepted without it:I, the camper's parent or legal guardian hereby give Camp Koinonia Staff and Counselors, and Emergency Personnel consent and permission to provide first aid and emergency medical treatment in the event my child is injured during the camp session. I am aware that this medical information form will be kept with the Camp Koinonia counselors, and that Camp Koinonia staff members will take precautions to keep this information confidential. I understand that many participants with a variety of medical/psychological difficulties can successfully participate in overnight camps, but it is my responsibility to make the Camp Koinonia staff aware of my child’s medical history. I acknowledge and understand that failure to truthfully and accurately disclose the required information in this form could result in serious harm to fellow participants and my child. I understand the rigorous nature of the camp. I understand that professional medical attention could be several hours away. I understand that I will be held responsible for the cost of an ambulance if my child requires one. I understand the importance of this form and have answered all statements fully and truthfully. I understand that if I am at all uncertain about my child’s ability to participate in this trip it is my obligation to consult my personal physician.SignatureClear SignatureIf you need to review your medical information, click previous to review. If you are ready to submit, click next.PreviousNextTo submit your medical information and release form for Camp Koinonia, click submit below.Submit
