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General Health History

Camp Type

W.A.R

C.L.I.M.B

L.E.A.D

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In case of emergency, notify the person below.

Allergies/Medications

Allergies and Adverse Reactions

Are you allergic to or do you have any adverse reaction to any of the following?

Personal Medications

List all medications currently used, including any over-the-counter-medications.

Medication options

Meds are taken Regular

Click here if no meds are routinely taken

I authorize Remembrance Ranch to administer over the counter medication.

Yes

Non-prescription medication administration is authorized with these exceptions.

Bring enough medication in sufficient quantities and in the original container. Make sure they are NOT EXPIRED, including inhalers and EpiPens. You SHOULD NOT STOP taking any maintenance medications unless instructed by your doctor.!!

Immunization

The following immunizations are recommended. Tetanus immunization is a required and must have been received within the last 10 years. If you have had the disease, check the disease column, and list the date. If immunized, check yes, and provide the year received.