Participant Medical Form

To be filled out by each adult participant and the parent/legal guardian of each girl attendee

Health History and Medical Information

Name of Family Physician:         Phone:

Family Medical/Hospital Insurance Carrier:         Policy or Group #:

Family Dental Insurance Carrier:         Policy or Group #:

Age: Weight:         Immunizations up to date: Yes   No   N/A         Date of last tetanus shot:

Date of last health examination:       Were there any problems at the time?

Has the participant had any recent injuries or surgery? Yes   No   If yes, please explain and specify date:

Is participant restricted or limited from participating in any physical activity?
          Yes   No   If yes, please explain:

Participant has the following health conditions:
ADHD/ADD   Asthma   Diabetes   Headaches   Seizures   Other:  

Allergies and treatments:

Over-the-Counter Medications Stocked at Jubilation

Indicate which of the following over-the-counter medications may be given to you or your girl by an Adult Leader or Camp Medical Staff. The examples given are not necessarily the brand that will be given, but are merely provided to assist you in choosing.

Please do not send any of the following over-the-counter medications to Jubilation.

Yes   No   Decongestant (Sudafed, Actifed, etc.)
Yes   No   Acetaminophen (Tylenol, etc.)
Yes   No   Sore Throat (Halls, Sucrets etc)
Yes   No   Ibuprofen (Advil, Motrin, etc.)
Yes   No   Antacid (Tums, Rolaids, etc)
Yes   No   Antihistimine (Benadryl, Dimetapp, Claritin, etc.)

Note: If your girl requires any over-the-counter medications not listed here, indicate them in the chart below.

Medication Coming From Home
  • You must list all prescriptions and medications that will be taken at Jubilation.
  • Medication MUST be in its original container with a non-expired original label.
  • All girl medication MUST be turned in to the leader, and the leader will then turn medication over to the nurse to dispense during the event.
  • Adults may either turn your medication in to the nurse, or keep them yourself in a locked container (cashbox, backpack with a padlock, etc.), however they MUST list all prescriptions and over-the-counter medications they plan to bring to the event.

Use the Special Instruction area to include reason for taking, how long taken, and any adverse effects actaully experienced.

MEDICATION INFORMATION

DOSAGE

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Name of Medication:

Special Instructions:

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By typing my name below, it is my intent to sign, accept and be legally bound by the terms of the agreements listed above as if I was affixing my handwritten signature, and I agree that this electronically signed document shall be as effective, enforceable and valid as a paper version bearing my original handwritten signature. By typing my name below, I further affirm that I am the above named Participant, or if the Participant is under 18 years of age, that I am a legal guardian or parent of the Participant and that I accept responsibility for the Participant's actions. I acknowledge that failure to submit accurate information, or falsification of the electronic signature on this document, may result in denial of participation in the Activity.