Camp Bethel 2024 Camper Health & Information Form
A parent or legal guardian must complete and submit this form at least 7 days prior to your camp dates or as soon as possible. Print a copy of this completed form for your records. The intent of this form is to provide information needed in case of emergency care. The directors keep information from this form confidential. Submit additional descriptions or updates if needed via CampBethelOffice@gmail.com, attention: Health Coordinator. Provide any urgent health updates at check-in on the first day of camp.

Insurance is not required for camp attendance, and Camp Bethel provides only limited secondary accident insurance for participants. If you have insurance and you have plans to be away or unreachable during your child’s camp time, you must e-mail a scan or image of the front & back of your family/child medical insurance card to CampBethelOffice@gmail.com, or upload the scan/image at www.CampBethelVirginia.org/health. In any emergency, illness, or injury, we will immediately contact the parent/guardian or the emergency contact.

The form works best on a laptop or desktop, but if you must use a phone or mobile device, PLEASE use correct spelling and capitalization, and be careful with tricky pull-down menus.

SCROLL THIS FORM DOWN AS YOU GO, and be sure to click the SUBMIT button at the bottom of the form!  Items with a red * asterisk are REQUIRED items.
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Email *
Camper's FIRST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Camper's LAST name *
Thank you for using correct capitalization for names and titles throughout this health form.
Camper's Date of Birth *
REQUIRED QUESTION:  month / day / year; M/D/YYYY; example: 3/9/2014  or  12/18/2006.
MM
/
DD
/
YYYY
Gender - male or female
At this time, our summer camp facilities are gender binary, and there is no single-room housing for minors. If you have questions, contact Kathleen Nettnin, Program Coordinator at 540-992-2940.
Clear selection
Dates of Camp Attendance *
Choose the dates that most closely match WHEN your child will attend camp.  Dates are shown as full weeks and may not exactly match your specific program.
First & Last Name of custodial Parent's/Guardian who is the primary contact for this camper. *
This is the parent/guardian(s) with whom the camper has primary residence and who is our primary contact.
City and State of residence. *
Thank you for using correct capitalization and correct state abbreviation.
Main phone of custodial Parent/Guardian *
include area code, (ex: 540-555-1234)
Other phone of custodial Parent/Guardian
include area code, (ex: 540-555-4321)
Emergency Contact Information
If we need to give important information to parents, but we cannot reach parents, who should we contact?
Who should we call if Parent/Guardian is not available? *
That person's relation to camper? *
Their main phone *
include area code, (ex: 540-555-1234)
Their other phone
include area code, (ex: 540-555-1234)
Who will pick up your child? *
List the first and last names of ALL adults who are AUTHORIZED BY YOU to drive the camper home from camp.
ALLERGIES & RESTRICTIONS
List all known allergies and restrictions.  Describe the severity of any allergies or restrictions, especially if allergy is life-threatening.  Describe your child's reaction and the best management of the reaction.  Describe the best accommodation, adaptations, or limitations of any restrictions.  If none, leave blank or write NONE.
Food allergies
Medication allergies
Other or environmental allergies
The following Dietary restrictions apply to this camper:
We can accommodate vegetarian, gluten-free, and nut-free diets. For other restrictions, please contact our office to discuss options.
Explain any restrictions or exemptions to camp activities:
What cannot be done; what adaptations, accommodations or limitations are necessary?
Other restrictions or health concerns?
MEDICAL HISTORY:
Describe any past or current injury, illness, disease, medical treatment, surgery, or affliction the camp should know in case of emergency.
ADDITIONAL INFORMATION:
Describe other physical, emotional, or behavioral concerns, or any conditions requiring medication, treatment, or special restrictions or considerations while at camp.
PERMISSION TO ADMINISTER OVER-THE-COUNTER MEDICATIONS: *
In case of headaches, low grade fever, slight upset stomach, mild diarrhea, mild allergic reactions, aches and pains, or cold symptoms, the Camp Bethel Health Coordinator has my permission to administer the following to over-the-counter medications (or their generic) to my child: Benadryl, Cold/Cough Medicine, Ibuprofen, Imodium AD, Pepto Bismol, Sudafed, Tums Antacid, and Tylenol for Children.
Exceptions to over-the-counter medications above
If you answered "Yes, but with my listed exceptions...", please list those over-the-counter medications listed above that you do NOT grant us permission to administer.
MEDICATION THAT WILL BE NECESSARY DURING CAMP:
If camper will require medication during camp (either prescribed, over-the-counter, as needed, etc), you must indicate "YES" below AND complete and return a paper copy of the "Camp Bethel Medication Instructions" form at: https://www.campbethelvirginia.org/uploads/1/1/0/2/11021295/campermedicationinstructions.pdf 
Will this camper need medication during camp? *
IMMUNIZATION HISTORY -OR- WAIVER:
This information is NOT REQUIRED for camp attendance, but if your child has been immunized, indicate details below. For families who voluntarily exempt their children from select school-required immunizations OR who voluntarily exempt themselves from providing proof of immunization, the following information is not required for camp attendance, but you must sign the waiver (2) below if you do not check YES below.
Do you attest that all immunizations required for school attendance are up to date for this camper? *
If you choose not to answer, you must sign the waiver in #2 below.
1. Tetanus Immunization month and year:
Due to the nature of camp, tetanus immunization is strongly recommended and may be helpful in case of emergency.  Write month and year of the most recent tetanus immunization for this camper.  DTP (diptheria/tetanus/pertussis), or TD (tetanus/diptheria), or Tetanus.  If you choose not to answer, you must sign the waiver in #2 below.
2. IMMUNIZATION WAIVER: If you chose not check YES above and/or to provide information in (1) above, please sign and date below by writing your name.
NAME AND DATE: Please sign the following statement:  “I understand and accept the potential risks to one who is not fully immunized.”
GETTING TO KNOW YOUR CAMPER
The following questions will help us ensure a quality camp experience for your camper.  Get your camper's opinion, remembering that our program focus is relational small-group community living, and your camper will spend all day each day with her/his group.  
Check all that apply
Swimming ability *
Indicate your camper's swimming ability.
Ability to ride a bike *
Indicate your camper's ability to ride a bike with no training wheels.
Describe your camper's personality when living, playing and working with others.
Camper's interests, hobbies, likes:
Knowing this will help your counselor to know you better.
As your camper thinks about camp, what EXCITES her/him?
Re-read the Confirmation Packet, the camp brochure and the program description to ensure your child's expectations match what will really happen.
As your camper thinks about camp, what CONCERNS her/ him?
Re-read the Confirmation Packet, the camp brochure and the program description to ensure your child's expectations match what will really happen.
What outcomes from this experience do you hope for your camper?
How did you learn about Camp Bethel's Summer Camps?
PLEASE ANSWER THIS QUESTION!  This information helps us greatly!  Do our printing/advertising/mailing efforts work?  Word of mouth?  Google search?  Facebook posts?  Event or fair?  Carrier pigeon?
I/ We chose Camp Bethel because:
Church Membership
... if any.  (this is NOT required for camp attendance, and ALL children/youth are welcome in our summer camps.)  If you are from a Church of the Brethren congregation, PLEASE answer this question.
Parent/Guardian Health Form Verification:
"I verify that the information on this Camper Health & Information Form is correct and complete as far as I know.  This form may be copied for camp records.  I will provide updates (if any) to this information at check-in the first day of camp."
I verify this information.  (This is a required question.) *
My signature below indicates that "I verify this information". Electronic Signature of Parent or Guardian (type your full name). After agreeing (typing your full name), be sure to SCROLL THIS FORM DOWN to the SUBMIT button in order to send us this camper Health information!
**To complete this form, click SUBMIT.
If you do not click "Submit" we will not receive your camper's information, so be sure to click SUBMIT.  Thanks!  Once submitted, you will be directed to a "Thank You" message with a link to the Confirmation Packets page of our web site.  Be sure to print/save your important Confirmation Packet.
A copy of your responses will be emailed to the address you provided.
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