Boychoir Bootcamp Health and Consent Form
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Camper's name *
Camper's age *
Camper's birth date *
Camper's address *
Does the child have medical insurance coverage? *
Please list type of plan, company and policy number(s)
Does the child have any drug or food allergies? *
If yes, please give pertinent details: What drugs or foods? What type of reaction occurs? How long ago did the reaction occur?
Is the child allergic to bee stings? *
If yes, what happens if the child is stung?
Does the child have any of the following conditions (please check box if yes)?
Does the child have any other medical conditions which may limit his or her participation in any camp activities, or which should be of special concern to the staff?
If yes, please explain in detail
IMMUNIZATIONS
Please list the date of the more recent vaccination, indicate "Up to Date," or write "Do Not Vaccinate."
M/M/R *
Hepatitis B *
Polio *
DPT/TD
Chicken Pox *
CONTACT INFORMATION
Physician's name and phone *
Name(s) of parent or guardian *
Best phone number(s) for parent/guardian *
In Case of Emergency Contact -- If parent/guardian cannot be reached, please contact: *
Please include: Name,  relationship to camper and phone number
PARENT/GUARDIAN PERMISSION FOR PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS
Boychoir Bootcamp staff must have consent from a camper's parent or guardian for each over-the-counter and prescription medication the child takes. Please indicate which over-the-counter medications you approve of, do not approve of, if your child is allergic to any of them, or if they have never taken the medication.
Current weight
For dosing purposes
*
Yes, Allowed
No, not allowed
Allergic
Yes, Chewable Form Needed
Acetaminophen (ex. Tylenol)
Ibuprofen (ex. Motrin or Advil)
Pseudoephedrine (ex. Sudafed)
Bismuth Subsalicylate (ex. Pepto Bismol)
Loperamide (ex. Imodium AD)
Dextromethorphan (cough suppressant)
Diphenhydramine (ex. Benadryl)
Dimenhydrinate (ex. Dramamine)
Calcium Carbonate (ex. Tums)
Medications during camp
Please list all prescription and over-the-counter medications the camper will take at Bootcamp. Include topical preparations, as well as dosage for all medications. Medications must be turned in to the staff, and will be administered according to the instructions provided by the parent or guardian.
PARENT/GUARDIAN CONSENT FOR EMERGENCY MEDICAL CARE
I give permission for the camper named above to receive emergency medical or surgical treatment and to be hospitalized if necessary.  I understand that every attempt will be made to contact me or the In Case of Emergency contact named above before such action is taken.
Parent/Guardian signature *
Your typed name constitutes sufficient signature
Date *
PHOTO RELEASE
I give permission for Boychoir Bootcamp and the Minnesota Boychoir to use photos/images of my child for promotional purposes
Parent/Guardian signature
Your typed name constitutes sufficient signature
Date
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