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Camp Ideal

Health Form

First Name *
Last Name *

Emergency Contact Information

Please specify two individuals to contact in case of an emergency.

First Name *
Last Name *
First Name *
Last Name *

Health Screening

Immunization & Illness History

Please upload your immunization records below, ask your physician to fax your documents to 574-400-2161 or email as soon as possible. Forms must be submitted no later than December 19.

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General Health Questions
Had any recent injury, illness or infectious disease?
Have a chronic or recurring illness/condition?
Wear glasses, contacts or protective eye wear?
Wear a hearing device?
Ever had a head injury?
Ever had frequent ear infections?
Ever passed out during or after exercise?
Ever been dizzy during or after exercise?
Ever had seizures?
Ever had chest pain during or after exercise?
Ever had high blood pressure?
Ever been diagnosed with a heart murmur?
Have a sleep disorder?
Diagnosed with Bipolar disorder?
Diagnosed with depression?
Diagnosed with anxiety?
Diagnosed with ADD/ADHD?
Diagnosed with psychosis?
Ever had back problems?
Ever had problems with joints (e.g. knees, ankles)?
Have orthodontic appliance being brought to camp?
Have any skin problems (e.g. rash, severe acne)?
Have diabetes?
Have asthma?
Had mononucleosis in the past 12 months?
Had problems with diarrhea/constipation?
Had problems with sleep walking?
If female, have an abnormal menstrual history?
Ever had an eating disorder?
Diagnosed with a psychiatric disorder?

Personal Care Information

We understand this information is extremely private. We will only utilize this information in the case of an emergency.

Care Providers

Health Agreement

This health information is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities, except as noted. I hereby give permission to the camp to provide basic first aid, administer prescribed or OTC medications as directed and seek emergency medical treatment including ordering x-rays or routine tests.  I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes.  I give permission to the camp to arrange necessary emergency transportation. In the event that I cannot be reached in an emergency, I hereby give permission to the physician/health care provider 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. I understand that the camp is not defined as an entity subject to HIPAA and therefore is not covered by HIPAA regulations concerning patient medical records.  I also understand and agree that situations may necessitate that my child’s medical information be shared with the appropriate staff as determined by the Jewish Federation. 

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