Please specify two individuals to contact in case of an emergency.
Please upload your immunization records below, ask your physician to fax your documents to 574-400-2161 or email [email protected] as soon as possible. Forms must be submitted no later than 2 weeks prior to your camper's first day.
We understand this information is extremely private. We will only utilize this information in the case of an emergency.
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.