Camp Courage

Camper Health and Insurance Information Form

Please complete the following information regarding your camper’s health and insurance. This will be used to ensure we can provide the best care during camp.

Camper's full name:(Required)

First Last

Health Insurance

Health insurance company name:(Required)

Subscriber’s name:(Required)

Contract number:(Required)

Group name:(Required)

Group number:(Required)

Health insurance company contact phone number:(Required)

Dental Insurance

Dental insurance company name:(Required)

Dental insurance company contact phone number:(Required)

Physician

Primary care physician’s name:(Required)

First Last

Physician’s phone number:(Required)

Medication and Allergies

Is your camper currently taking any medications?(Required)

Yes

If yes, please list any medications your camper is currently taking below:

Does your camper have any allergies to medications?(Required)

Yes

If yes, please list the allergies below:

Agreement and Acknowledgment

By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I give permission for the camp staff to use this information as needed to provide appropriate care for my camper during their time at camp.

Parent/legal guardian – printed name:(Required)

First Last

Parent/guardian signature:(Required)

Date:(Required)

Bereavement counselor signature:

Date:

Hospice Care

Palliative Care

Grief Support

Paying for Services

Camper Health and Insurance Information Form

Health Insurance

Dental Insurance

Physician

Medication and Allergies

Agreement and Acknowledgment

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