Health Information Form | Seattle Children's Museum

Your Name:*

First Last

Camper's Name:*

First Last

Camper's Birth Date:*

MM

DD

YYYY

Email Address:*

Enter Email Confirm Email

Make sure you enter your email address accurately. You will get a copy of this form sent to the email address above after you hit submit.

ALLERGIES

This camper is allergic to:*

No known allergies.
Food
Medicine
Environment (insect stings, hay fever, etc)
Other

Please describe what the camper is allergic to and the reaction seen.

MEDICATIONS

Will this camper take any daily medications while attending camp?*

This camper will not take any daily medications while attending camp.
This camper will take the following daily medications while attending camp, AND will bring a physician note, prescription or label along with the medication:

Please describe the medication and how it should be used.*

Will this camper be bringing other medication to be used as needed?*

This camper will not be bringing other medication to camp
This camper will bring medication to camp to be used as needed, AND will bring a physician note, prescription or label along with the medication.

Please describe the medication and how it should be used.*

Would you like sunscreen to be applied before our lunchtime outdoor play session?*

Yes, and I understand that the camper must bring their own sunscreen and that SCM educators will only apply spray-on sunscreen to campers. My camper will be responsible for applying any other type of sunscreen themselves.
No

FIRST AID

Please indicate if you would prefer the following items NOT be used on your camper on an as needed basis to manage illness and/or injury.

Band-Aid, or other generic bandages
Cold Compress

SCM Camp Staff are trained in basic First Aid. If any injury or illness were to need attention beyond that, we would immediately contact EMS and/or caregivers.

Are you sure you DO NOT want us to use these first-aid items on your camper?*

I'm sure

DIET AND NUTRITION

Please indicate your camper's diet:*

No Dietary Restrictions
Vegetarian
Vegan
Lactose free
Gluten free
Other

Describe your camper's food needs (if applicable):

RESTRICTIONS

Please check all that are true:*

This camper uses special equipment such as a breathing machine, wheelchair, hearing aid, braces, etc (if yes, please describe below).
I have reviewed the program and activities of the camp and feel the camper can participate without restrictions (if no, please describe below).
This camper functions at the level of other children in his or her age group (if no, please describe below).
This camper can effectively communicate his or her needs in English (if no, please describe below).
This camper can routinely and successfully use the toilet without assistance. (if no, please describe below)

Please note:
- In case of an emergency, it is critical for campers to be able to understand and follow basic directions given by our staff. To ensure the safety of all participants, SCM therefore requires campers to be proficient in English.
- We understand that accidents happen. However, SCM does not have sufficient resources to provide regular bathroom assistance to campers and therefore generally cannot accept campers who routinely require such assistance.

Please explain any of the applicable statements above:

Please check all statements that are TRUE. Explain all true statements in the space provided below. Has/Does the camper. . .*

Please explain all ‘TRUE' answers above. Our staff may contact you for more information. For travel outside the country, please name the countries visited and dates of travel.

MEDICAL INSURANCE INFORMATION:

SCM does not provide accident or illness insurance.

This camper is covered by family medical/hospital insurance*

Yes
No

Insurance company:

Subscriber:

Policy Number:

Insurance company phone number:

HEALTH CARE PROVIDERS:

Name and phone number of camper's primary doctor:*

Name and phone number of camper's primary dentist:*

CAREGIVER AUTHORIZATION FOR HEALTH CARE:

Please check items that are "TRUE":*

This health history is correct and accurately reflects the health status of the camper to whom it pertains. If changes occur, I will alert SCM before the camper attends camp.
The camper described has permission to participate in all camp activities except as noted by me and/or an examining physician.
If SCM notifies me that my child is ill, I must pick my child up as soon as possible and no later than one (1) hour after being contacted.
I understand the information on this form will be shared on a ‘need to know’ basis with camp staff and medical personnel.

Please read carefully. All of the above statements are required.

In case of a medical or other emergency while my child is under SCM’s supervision, I understand that SCM staff will attempt to contact me immediately; however, in the event that I cannot be reached, or when a delay would further jeopardize my child’s health, I hereby authorize SCM to act on my behalf and to take the emergency measures including those listed below if deemed necessary by SCM staff or by medical authorities for the care and protection of my child. I authorize SCM to:*

Administer first aid and/or cardiopulmonary resuscitation.
Obtain any emergency medical or dental treatment deemed necessary by medical authorities.
Transport my child via ambulance or other emergency medical service to a local hospital and other urgent care facility, if deemed necessary by paramedics, police, or other emergency personnel.

IMMUNIZATION

Please check the immunizations for which the camper is up to date:*

Diptheria, tetanus, pertussis (DTap or TdaP)
Mumps, Measles, Rubella (MMR)
Polio (IPV)
Haemophilus influenza type B (HIB)
Hepatitis A
Hepatitis B
Varicella (Chicken Pox) - please also check this box if the camper has had Chicken Pox
None of the Above

When was the camper's last tetanus shot? (month and year)*

I understand and accept the risks to my child from not being fully immunized.*

My child is fully immunized
I do

What have we forgotten to ask?

Is there any additional information about your child, their routine, or particular needs you would like to share? Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program.

Health & Medical Information Form