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 Camper's Personal Information

 Camper's Healthcare Provider Information


Does this allergy cause anaphylaxis?
Does this allergy cause anaphylaxis?
Does this allergy cause anaphylaxis?



 Medication or Treatment 

 When do you give it at home? 

 Reason for taking medication 


Asthma Triggers
(check all that apply)

of asthma episode

Frequency of episodes

How episode is managed

 upload immunization record OR complete section below

Upload Immunization Record

List the MONTH, DAY, AND YEAR your child received each of the following immunizations.  DO NOT USE checkmark or X except to answer the question about chickenpox, Tdap or Td.  If you do not have an immunization record for this child at home, contact your doctor or public health department to obtain it.  A copy of the child's complete immunization record (Wisconsin residents check may be uploaded in lieu of completing this section by using the +Upload button above.

Type of Vaccine*

First Dose

(Diphtheria, Tetanus, Pertussis)

Second Dose

Third Dose

Fourth Dose

Fifth Dose

Adolescent booster (mark which)


Hepatitis B

MMR (measles, mumps, rubella)

Meningococcal Conjugate Vaccine (MCV)*

Hepatitis A

Varicella (chickenpox) Vaccine - 
vaccine is needed only if your child has not had chickenpox disease.  See below:

Has your child had Varicella (chickenpox) disease?  Please check appropriate box and provide the date (if known):

Influenza (date of most recent dose):

Vaccines above marked with * are routinely recommended at age 11-12 years.

List vaccine(s) not received:

 Other Medical Conditions

 Signature (use mouse to draw signature)

The information included on this form is complete and accurate to the best of my knowledge.

medical history form submitted!

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