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Dear Parents, Guardians, and Staff: Welcome to the Cazadero Camp Health History Form. The information collected here is used to help us keep everyone safe and healthy while in our care. All information is confidential; only shared on a need-to-know basis.

This form will ask for some information that you might want to have ready before you begin:
  1. image files of your camper's medical insurance card, front and back. 
  2. immunization records: these can be entered by hand or uploaded as an image file.
You can stop and save your work, and come back later to add information. Look for the links at the top and bottom of the page and follow the instructions.

Note: This is our standard pre-COVID Health History Form. COVID specific safety issues will be addressed in a separate form.

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Participant Information

Primary Contact: Parent/guardian with legal custody

Second Parent/guardian or other emergency contact

Additional contact in the event parent/guardians cannot be reached

Primary Emergency Contact: 

Second Emergency Contact:

Additional contact: 

Allergies: Medications or the Environment

Food: Allergies, Diet, and Nutrition

Activity Restrictions

Medical Insurance Information and Consent to Treat Authorization

International Insurance

Health Insurance and Policy Information

Medical Insurance ID Card
To complete this section please upload a copy of the participant's insurance card, front and back. This ensures that we can quickly access all the information we will need in the event of an emergency. 

Please send JPEG or PDF files.

Consent to Treat
Consent to Treat/Uninsured
Authorization for Health Care
I understand that typing my name below constitutes a legal signature indicating agreement to the above Authorization for Health Care.

Please type your first and last name

Health Care Providers

Immunization History

COVID booster (most recent)
Tetanus booster (most recent)
Tuberculosis TB Test

Immunization History

Please type your first and last name

Immunization Dates
Dose 1 Dose 2 Dose 3 Dose 4 Dose 5
COVID-19 primary and boosters
Diptheria, tetanus, pertussis (DTaP or TdaP)
Tetanus booster (most recent)
Mumps, measles, rubella (MMR)
MMR Booster?
Polio (IPV)
Haemophilus influenzae type B (HIB)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (Chicken Pox)
Had Chicken Pox? Let us know when.
Meningococcal meningitis (MCV4)
Tuberculosis: if tested, date and results.

"Medication" is any substance a person takes regularly to maintain and/or improve their health. This includes vitamins & natural remedies, over-the-counter medications, and prescriptions. 
Medications while at camp
Please read these instructions before sending any medications with your camper.
You must follow these packaging instructions or we will be forced to discard the medications as unsafe and contact you for replacements.

  • All medications, whether prescription or over the counter, must arrive in their original packaging
  • Prescriptions should have the pharmacy label showing the camper's name, dosage, and how the medication should be given.
  • Check the expiration date; no expired medications can be administered at camp.
  • Provide enough of each medication to last the duration of the camper's time at camp.

On-Site Health Center

General Health History
Please check "yes" or "no" for each statement and explain "yes" answers below. 

Has or does this participant...
Yes No

Mental, Emotional, and Social Health
We want to take the best possible care of your camper; please check "yes" or "no" for each statement. 
Has your camper:
Yes No

Is there anything else you would like us to know?

Stop Sign
Save a copy of your responses for your records. 

After hitting "submit" you will be asked to confirm your submission a second time; this step allows you to make a printout or PDF file copy of your responses. You cannot come back to the form after you hit submit that second time and your doctor's office will need to see your responses before signing a "fit to participate" form.

Thank you!
Contact information for Cazadero

Cazadero Performing Arts Camp • P.O. Box 7908 • Berkeley • CA • 94707 

Phone 510.527.7500, email, or visit