CAMP AMERICA MEDICAL FORM 2024
SECTION B
SECTION B - TO BE COMPLETED BY PHYSICIAN ONLY (who should not be a relative of the applicant)
Has the applicant ever suffered from...
Yes
No
1. Any chronic/recurring illnesses:
2. Any operation, serious injuries or any other pre-existing medical conditions:
3. Any hospitalisations of more than 3 consecutive admission days:
4. Any mental illness/eating disorder or self-harm:
5. Any developmental disorders (e.g. Aspergers, Autism, OCD):
6. Any suicide attempts/ideations:
To your knowledge has the applicant ever been the victim of the following:
Sexual Abuse: YES NO Emotional Abuse: YES NO
Are there any emotional/mental issues that would prevent this applicant from caring for children? YES NO
Are there any limitations to any physical activities? YES NO
Recommendation for Physical Activity: * Limited *Please Explain if Limited Unlimited
Please provide name and dosage of all medications applicant is currently prescribed to take and to which condition they
relate, please include allergies. (Patient will require up to three months supply of all medicines)
Medicine: ......................................................................... Condition: .............................................................................
SECTION A - TO BE COMPLETED BY APPLICANT
First Name:___________________________________ Last Name:__________________________ Female / Male
Age: _________ Date of Birth: ____/________/________
Emergency Contact / Next of Kin Information
First Name: __________________________________ Last Name: __________________________
Relationship: __________________________________ Contact Number (incl. country code): _______________________
Camp America must be notified if you are exposed to a communicable disease/serious injury or of any other changes to your general
medical condition after completion of this form, including sprained/broken limbs which may impair performance. I confirm the information
on this form is correct to the best of my knowledge. Should any emergency arise, I authorise Camp America Staff and any medical
provider to release information regarding my condition to camp or their insurance provider/emergency services and I understand they
can contact my next of kin or my nominated emergency contact without my prior consent. It is your responsibility to ensure you are fully
vaccinated including any boosters advised by your GP. Some Summer Camps may require additional vaccinations, speak with your camp
directly for more information. Participants will be included in the programme Accident & Sickness Group coverage and for this purpose
your medical history will be shared with the coverage provider. By signing this form I confirm I have read the privacy policy
(see
www.culturalinsurance.com link at bottom of the homepage) and I confirm that I give permission for my doctor to supply my medical
information to Camp America.
Signature: ............................................................................. Date: ..............................................................................
Please provide details (including approximate dates) if you have answered ‘YES’ to any of the above:
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Any issues with the following...
Yes
No
Yes
No
Heart
Asthma
Lungs
Diabetes
Migraines
Tuberculosis
Back Conditions
Rheumatic Fever/Heart Disease
Fainting/Dizziness
Concussion/Head injuries
Sleep Walking/Night Terrors
Measles
Depression
Mumps
Generalised Anxiety
Whooping Cough
Self-Harm
Cancer
Attempted Suicide
Had Chicken Pox
Eating Disorders (Anorexia/Bulimia)
Obsessive Compulsive Disorder
Other: ..........................................................................
Susceptibilities
Convulsions/Epilepsy: YES NO Date of last seizure: .......................................................
Other (please specify): ....................................................................................................................................................
Immunisations – please complete or alternatively print off vaccination records and attach.
Please check with your camp as they may require specific vaccinations.
Immunisation
Dose 1
(Month/Year)
Dose 2
(Month/Year)
Dose 3
(Month/Year)
Dose 4
(Month/Year)
Dose 5
(Month/Year)
Most Recent
Dose
(Month/Year)
MMR - Mumps/
Measles/ Rubella
Meningitis
Diphtheria/ Pertussis/
Tetanus
Polio (Sabin)
Hepatitis A and B
Typhoid
Whooping Cough
Chicken Pox
COVID-19 Vaccine
Type of
vaccine:
Do you have access to the patient’s full medical history: YES NO
How long have you been treating the patient?................
DOCTORS WILL NOT BE HELD LIABLE FOR THE INFORMATION PROVIDED IN GOOD FAITH TO CAMP AMERICA
DOCTOR’S SIGNATURE: ...................................................... DATE: ......................................
PLEASE PRINT NAME: .........................................................................................................
PHONE NO.: ......................................................................
EMAIL ADDRESS: …………………………………………………………………………………………………………
Yes
No
Tuberculin Test Given?
Date: ....................................
Positive Negative
PLEASE STAMP
UK: 37A Queens Gate, London, SW7 5HR Germany: Friedensplatz 1, 53111 Bonn, Germany
Poland: ul. Grzybowska 43 pok. 220, 00-855 Warsaw, Poland Australia: 10-14 Oxford Square, Darlinghurst NSW 2010
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