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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.

If you would like to be able to stop, save your work, and come back later to add information, check the box at the top of this page. Look for the links at the top and bottom of the page.

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




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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

Boosters
Dose 1
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
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 TB Test


Medications
"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

Yes No

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?


After hitting "submit" you will be asked to confirm your submission a second time. This step allows you to make a printout of your responses if you would like a copy for your records. Please make a copy for yourself, you cannot come back to the form after you finally submit your form.

Thank you!
Contact information for Cazadero

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

Phone 510.527.7500, email emily@cazadero.org, or visit www.cazadero.org