Medical Form

Medical Form

Fill out your campers medical information carefully. One form per each camper or staff member.
Full Name:*

First NameLast Name
Date of birth of Camp Tzadi participant:*

MonthDayYear
MEDICAL HISTORY:
Any food, medication or environmental allergies?*

YesNo
Please list and explain any allergies:
Does the camper or staff member carry an EpiPen with them?*

YesNo
Is the camper or staff member up-to-date on all childhood immunizations?*

YesNoOther
NO CHILDHOOD IMMUNIZATIONS:

I have not immunized my child(ren) due to my specific allergic, religious or personal beliefs. Therefore, I am signing this waiver taking full responsibility for all medical matters regarding my child that may result from not having the specified immunizations. Furthermore, I do NOT hold Camp Tzadi, 12-21 Initiative, First Fruits of Zion or Vine of David responsible and/or liable for any health care needs that may arise due to the absence of specified immunizations during his/her stay at Camp Tzadi
Authorization that camper/staff is not fully immunized to current health standards:

Clear
Date

MonthDayYear
Date
Please select any or all that apply:*

Had any recent injury or infectious disease?Has ever had a head injuryHas frequent headachesHas ever had chest pain during or after exerciseHas high blood pressureHas diabetesHave problems with sleep walkingHad mononucleosis in the past 12 monthsHas joint pain or stiffnessHas arthritisHas ever been diagnosed with a heart murmurHas ever had an asthma attackHas ever had a seizureSuffers from frequent ear infectionsHas had a chronic or recurring illness or condition?Has ever fainted or been knocked unconscious?Has ever passed out during during or after exercise?Has ever been hospitalized long termHas ever had surgeryHas ever had any threats of self-harm or suicideHas ever participated in recreational drugs or alcoholHas an orthodontic appliance being brought to campIf female, have an abnormal menstrual cycleA history of bed wettingHas problems with GI (such as: diarrhea/constipation/blood in stool)Has a life-threatening allergyNone of the above apply to my camper
If any of the above items were checked, please write a description that will help the staff provide proper care and attention for the camper or staff:
Injuries: Has the camper/ staff suffered from any of the following injuries?*

HeadHipNeckElbowChestForearmBackWristHipHandShoulderThighArmAnkleEyeFootNo major injuries
If marked, please explain the injury:
Please note any significant medical history (such as: surgery, injuries, serious illness):
Mental Health: Has the camper/staff had/have any of the following?*

DepressionAnxietySocial AnxietySevere homesicknessSeparation AnxietySelf-HarmEating DisordersInsomniaFits of AngerSuicidal ThoughtsDoes not suffer from a mental health conditionOther
If marked, please explain in order for the staff to best assist the camper/staff member:
Is any medication required for the mental health condition?*

YesNoOther
In an emergency does this child or staff member require additional assistance (more than other children of the same age or in the same group)?*

YesNo
Please describe:
In the event that the campus must be evacuated, is there any medications or supplies that must be taken with this child or staff member?*

YesNo
PERMISSION TO TREAT

Camp Tzadi provides a certified nurse and EMT on campus. Should your camper need to be treated the following medications will be use and documented upon treatment.
Ailment/Symptom - Medication

Headache/Fever - Tylenol/Advil (or generic equivalent)
Upset Stomach - Tums, Pepto (or generic equivalent)
Vomiting - Emetrol, Nausetrol (or generic equivalent)
Minor Allergies - antihistamine, Benadryl, Claritin
Poison Ivy - anti-itch cream
Insect Bites/Stings - antiseptic, anti-itch cream
Insect repellent applied to campers before campout or whenever deemed appropriate by camp staff (may contain DEET)
Diarrhea - Kaopectate (or generic equivalent)
Sunscreen - campers are expected to provide and apply their own sunscreen; however, in the case of very young or very fair campers, camp staff may assist campers.

Dosage for all of the above medications will be as directed on the package.
PERMISSION TO TREAT:

I give my permission to the medical staff of the Camp Tzadi to provide medical treatment for my child. If I cannot be reached, in the case of an emergency, I hereby grant permission to the physician selected by the medical staff to hospitalize, secure proper treatment for, and to order injection, anesthesia, surgery or other treatment as deemed appropriate by the physician for the above mentioned camper.
I hereby permit Camp Tzadi to provide the treatment described above. Camp Tzadi will honor special instructions noted on this page.I do not grant permission for Camp Tzadi to administer over the counter medications or topical lotions as described above. This option will require Camp Tzadi medical staff to obtain your verbal permission before treating any non life-threatening emergency, regardless of the date or time of the injury or illness.
Authorization to give medication at camp:

Clear
MEDICAL INSURANCE:

If camper or staff does not carry insurance, see below:
Name of Insurance Company:
Policy Number:
Expiry Date:

DayMonthYear
Please upload an image of campers insurance card:

Browse Files

Cancelof
No Health Insurance:

I do NOT have health insurance; therefore, I am signing this waiver, taking full responsibility for all medical matters regarding my child. I take full responsibility for any expenses related to my child’s health, be it hospitalization, medicine, or any other cost related to injury or illness while my child attends camp at Camp Tzadi. Furthermore, I do NOT hold Camp Tzadi, 12-21 Initiative, First Fruits of Zion or Vine of David responsible and/or liable for any and all costs relating to my child’s health care for any reason during his/her stay at Camp Tzadi.
Authorization that camper/staff does not have health insurance:

Clear
Date

MonthDayYear
Date
EMERGENCY CONTACT

In case of an emergency, Camp Tzadi will call 911 or the proper authorities. After emergency services have been called we will contact the emergency contact listed for your camper.
Name of Emergency Contact:*

First NameLast Name
Relationship to the participant:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone #1:*

Area CodePhone Number
Phone #2:*

Area CodePhone Number
ADDITIONAL INFORMATION:
Is there anything else you would like Camp Tzadi staff to know about your camper in regards to their health or participation at camp?
Should be Empty:

Medical Form

MEDICAL HISTORY:

PERMISSION TO TREAT

MEDICAL INSURANCE:

EMERGENCY CONTACT

ADDITIONAL INFORMATION: