Fall Creek Christian Campground
CHRISTIAN
YOUTH CAMP
P O Box 717, Pikeville TN 37367
423-881-5400
~ MEDICAL INFORMATION ~
CAMPER'S NAME: ___________________________________
AGE: ________________________
CHILD'S FAMILY DOCTOR: ____________________________
PHONE #: _____-_____-_________
EMERGENCY NUMBERS OF PARENTS OR GUARDIANS:
Father’s name: _________________ Mother’s
name: _________________
Home: ______/______/________
Home: ______/______/________
Mobile: ______/______/________ Mobile: ______/______/________
Work: ______/______/________
Work: ______/______/________
Other: ______/______/________ Other:
______/______/________
ALLERGIES:
_______________________________________________________________________________
MEDICATION:
DOSAGE:
FREQUENCY:
_____________________
_____________________ _____________________
_____________________ _____________________
_____________________
_____________________
_____________________ _____________________
_____________________ _____________________
_____________________
_____________________
_____________________ _____________________
IF
CAMPER HAS REACTION, EXPLAIN HOW IT AFFECTS THEM AND WHAT SHOULD BE DONE.
__________________________________________________________________________________________
DATE OF LAST TETANUS SHOT? _______________ ARE SHOTS UP TO DATE? ______________________
DOES CAMPER HAVE ANY PROBLEM THAT STAFF SHOULD BE AWARE OF? If so, please explain. __________________________________________________________________________________________
PERSON PICKING UP CAMPER ON THURSDAY? ________________________________________________
NAME
OF CAMPER'S HEALTH INSURANCE CO: _________________________________________________
TELEPHONE
#: ______-______-________ INSURANCE CARD #: _________________________________
WILL CAMPER HAVE HEALTH INSURANCE CARD? __________________ or COPY? ___________________
As the parent or guardian,
I give my permission for my child to receive emergence medical treatment for accident or illness.
______________________________________________
DATE: ______/______/______
SIGNATURE OF PARENT (S) OR GUARDIAN
FCCC-111 (11/05)
