The American Camp Association's model camper health form, developed with the AAP Council on School Health and the Association of Camp Nurses, comes in two parts. Parents complete Form 1, a health history with immunizations, medications and consent for care. Form 2, Camper Health-Care Recommendations, goes to the child's health-care provider with a copy of Form 1 for review, activity restrictions and a signature before day or resident camp.
Parents or guardians complete pages 1 to 3 of Form 1 and the top of Form 2. The child's health-care provider (physician, NP or PA) reviews the copy of Form 1 and completes and signs Form 2; page 4 of Form 1 is reserved for camp health staff.
The page opens with camp dates, camper name, sex, birth date, age on arrival and the date by which the form must reach camp. Four numbered instructions tell parents to complete pages 1 to 3, copy them, send the signed original to camp, and pass the copy with Form 2 to the child's health-care provider. Parents then list the home address, the custodial parent to contact, a second parent or emergency contact, and an additional contact.
Parents check no known allergies or name allergies to food, medicine, the environment or other, describing what the camper is allergic to and the reaction. Diet choices are regular, vegetarian, lactose intolerant, gluten intolerant or other. Under Restrictions, the parent states they reviewed the camp program and the camper can take part without restrictions, or lists restrictions or adaptations, which the provider can compare with Form 2.
Parents give insurance company, policy number and subscriber, and may attach both sides of the card. The authorization lets a camp-selected physician order x-rays, routine tests and treatment, and in an emergency hospitalize or order injection, anesthesia or surgery if parents cannot be reached. It allows the camp to obtain the child's health record from treating providers, who may talk with camp staff. Parents unable to sign for religious or other reasons contact the camp for a legal waiver.
Parents give the month and year of each dose of DTaP or Tdap, tetanus booster, MMR, polio, Hib, pneumococcal, hepatitis B, hepatitis A, varicella (or the date the camper had chicken pox) and meningococcal vaccine, plus any TB test date and result. Starred immunizations must include a date to meet the ACA Standard, and copies of provider or government records are acceptable. An unimmunized camper's parent signs a risk statement.
Parents check that the camper takes no daily medication at camp or list each one with date started, reason, time given, dose and how it is given. The form defines medication to include vitamins and natural remedies, notes many states require original pharmacy containers labeled with the camper's name and directions, and asks for enough for the whole stay. Parents cross out any stocked over-the-counter medicine the camper should not be given.
Twenty yes/no questions cover hospitalization, surgery, chronic illness, recent infection or injury, asthma, diabetes, seizures, headaches, eyewear, fainting, chest pain during exercise, mono in the past 12 months, menstrual problems, sleep, back or joint problems, bedwetting, bowel problems, skin problems and travel abroad in the past 9 months. Four more ask about ADD/ADHD treatment, emotional or eating disorders, recent mental health care and significant life events. Parents explain Yes answers by number and name the camper's doctors, dentist and orthodontist.
Parents stop at page 3. Camp health staff use page 4 on arrival to record the initial screening date and time and whether the camper shows signs of illness or injury, exposure to communicable disease, corrections to the history, medication handed to staff or head lice. Staff add dated, initialed notes during the session and an exit note recording any problem and who was told about follow-up.
Form 2 is the provider's part, which ACA lists as Camper Healthcare Recommendations by Licensed Medical Personnel. The parent completes its top section, and the child's physician, nurse practitioner or physician assistant reviews the copy of Form 1, records health-care recommendations and any activity restrictions, and signs. The parent then returns Form 2 to the camp by the date the camp requested.
Download the current version from the source each time; forms change without notice.
Camper Health History Form (Form 1) and Camper Health-Care Recommendations (Form 2)
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Sources for this guide
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The child's health-care provider. Form 1's instructions tell parents to complete the top of Form 2 and give it, with a copy of the completed Form 1, to the child's health-care provider for review and completion. Once the provider has signed it, the parent returns Form 2 to the camp by the requested date.
No. ACA describes its forms as samples and says camps may, but are not required to, use them to meet ACA standards. Camps can create their own forms and decide, with their health care staff and legal counsel and under state law, what information to collect.
Form 1 lists each daily medication with the date started, reason, time given (breakfast, lunch, dinner, bedtime or other), dose and route. It notes many states require original labeled pharmacy containers and asks families to send enough for the whole stay. Parents also cross out stocked over-the-counter medicines the camper should not receive.