Camper’s Health Form

Haga clic aquí para español

To be completed by camper’s doctor/physician by May 1, 2025. Physical exams made before July 23, 2024 will not be accepted. If you have any questions about this form please email [email protected] with subject header “YLC Camper Completed Health Form”.

Camper's Full Name *

First Middle Last

Date of health exam *

Camper's Birthdate *

Camper's Height *

Camper's Weight *

Camper's Blood pressure *

Camper's Gender *

Camper's Sex Assigned at Birth *

Other:

Hair color *

Eye color *

Please check if the camper had any of the following health problems. If you checked yes, please explain the comment box provided below.

Health History Information

Elaborate on any of the items checked above:

I.E. “Allergic to bees – must have epi pen.”

Add any other history that is not listed above:

Any chronic or recurring illnesses? *

Add info about chronic/recurring illnesses: *

Any dietary requirements, restrictions, or allergies? *

Add dietary requirements, restrictions, or allergies: *

Has the camper been exposed to anyone who is at risk for latent Tuberculosis infection or has TB disease? IF so – when was the campers last Tuberculosis test?

Does the camper carry an epinephrine pen? *

For what? *

Any additional physical/mental health considerations?

Is the camper currently on medications? *

Please list all medications, dosage and what medication is treating. *

Immunization History DPT

Please list ALL of your immunization shots including year(s) of immunization and last booster.
(e.g. Tetanus/Diphtheria – shot 1998, booster 2008)

Here’s a list of typical shots:
Tetanus/Diphtheria
Tetanus (alone)
Oral Polio (Sabin)
Injectable Polio (Salk)
Measles (Rubeola)
Measles (Rubella)
Mumps

By submitting this form, I certify that I have on this date examined the above named camper and that on the basis of my examination and the medical history as furnished to me, I have found no reason that would make it medically inadvisable for this camper to participate in physically strenuous activities.

Licensed Physician's name *

First Last

Licensed Physician's address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Licensed Physician's daytime phone number *

Licensed Physician's emergency/evening phone number *

Signature

2025 YLC Camper Health Form