Mississippi Christian Service Camp
PO Box 6
Newton, MS 39345
Medical Form
Health History Form
Program
Name:
 Age:
Date of Birth:
Home Address:
Include City,
State and Zip
Social Security Number:
Gender:
Female
Male
Insurance Information
Is the participant covered by family medical/hospital insurance?
Yes
No
If so, indicate carrier or plan name:
Group #:
Photo copy front and back of insurance card and bring with you to camp.  We must have this.
Important -- The following 1 and 2 must be completed for participation.
1.  Parent / Guardian Authorization:  This health history is correct and complete as far as I know, and
the person herein described has permission to participate in all camp activities except as noted.

I hereby give permission to the camp to provide routine health care, administer prescribed medications,
and seek emergency medical treatment including ordering x-rays or routine tests.  I agree to the release
of any medical records necessary for insurance purposes.  I give permission to the camp to arrange
necessary related transportation for me / my child.  In the event I cannot be reached in an emergency, I
hereby give permission to the physician selected by the camp to secure and administer treatment,
including hospitalization, for the person named above.  This completed form may be photocopied for
trips out of camp.
Signature of parent/guaridan or adult camper/staff:
 Date:
2.  I also understand and agree to abide by any restrictions placed on my participation in activities.
Signature of minor or adult camper staff:
Date:
List all kn own allergies, i.e. Medication allergies,
food allergies, and other allergies (including insect
stings, hay fever, asthma, animals, etc.)  Also
describe reaction and management of the reaction
beside the allergy.  
Medications Being Taken
Please list all medications (including over-the-counter or nonprescription drugs) taken routinely.  Bring
enough medication to last the entire time at camp.  IMPORTANT:  Keep Medications in the original
packaging/bottle that identifies the prescribing physician (if a prescribed drug), the name of medication,
the dosage, and the frequency of administration.
Please check:
This person takes NO MEDICATIONS on a routine basis.
This person takes medication as follows:
List the medications in this fashion: Med.
Name #!  Dosage and Specific times to be
taken. And also the reason for taking.
General questions:
1.  Had any recent injury, illness or
infectious disease?
Yes
No
If yes, explain
2.  Have a chronic or reoccurring
illness/condition?
Yes
If yes, explain:
No
3.  Ever been hospitalized?
Yes
 No
If yes, explain:
No
4. Ever had surgery?
Yes
If yes, explain:
5.  Have frequent headaches?
Yes
 No
If yes, explain:
6.  Ever had a serious head injury?
No
 If yes, explain:
Yes
7.  Ever been knocked unconscious?
 No
 If yes, explain:
Yes
8.  Wear glasses, contacts, or         
      protective eyewear?
No
 If yes, explain:
Yes
9.  Ever had frequent ear infections?
Yes
No
 If yes, explain:
10.  Ever passed out during or after
    exercise?
Yes
 No
 If yes, explain:
11.  Ever had chest pain during or
    after exercise?
If yes, explain:
No
Yes
Yes
No
 If yes, explain:
12.  Ever had seizures?
Yes
 No
 If yes, explain:
13 Ever had high blood pressure?
No
 If yes, explain:
14.  Ever been diagnosed with a heart
       murmur?
Yes
Yes
 No
15.  Ever had problems with joints (e.g.
       knee's, ankles)?
If yes, explain:
Yes
If yes, explain:
No
16.  Have any skin problems?
17.  Have diabetes?
Yes
No
 If yes, explain:
Yes
No
 If yes, explain:
18.  Have asthma?
Yes
19.  Had mononucleosis in the past
      12 months?
No
 If yes, explain:
20.  Had problems with diarrhea /
      constipation?
 Yes
 No
 If yes, explain:
21.  Have problems with sleepwalking?
Yes
 No
 If yes, explain:
22.  Have a history of bed-wetting?
Yes
 No
 If yes, explain:
23.  Ever had a eating disorder?
Yes
 No
 If yes, explain:
Use this space to provide any additional information about the participant's behavior and physical,
emotional, or mental health about which the camp should be aware:
Explain any restrictions to activities (e.g.) what cannot be done, adaptations or limitations necessary).
Name of Family physician, their
address and phone number:
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