Medical Form

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MEDICAL FORM

Camper Full Name

Last, First, Middle

______________________________________________________________________________________________

Insurance Company

Ins. Co. Address

Ins. Co. Phone #

Insurance Company

Name of Policy Holder

Ins. Policy #

______________________________________________________________________________________________

Childhood Diseases

Date of last Tetanus

mm/dd/yyyy

Any Known Allergies?

If yes, please list allergies, reactions and treatment.

Does Camper

Sleepwalk Bed wet Faint Have Epilepsy Have Diabetes Have Asthma

Please check all that apply.

Explanation for checking above:

Current Medications Taken

Include name, current dosage, and reason for taking.

I give permission for forenamed camper to receive as necessary:

Tylenol Antacid Ibuprofen Sinus Medication

Other Permissible Medications

Special Instructions

Use this area to tell us about any other instructions about medical care, medication, or treatment.

______________________________________________________________________________________________

Doctor's Name

Normal Physician

Doctor's phone number:

(123)123-1234

______________________________________________________________________________________________

Electrionic Signature

The name of the person filling out this form. Must be a Parent / Guardian, if under 18.

The last 4 digits of your SSN

To verify that you are who you say you are, please input the last 4 digits of you Social Security Number (xx-xxx-1234).

Select date

Bible Impact Ministries
Whispering Winds Bible Camp
599 Mound Ridge Road
Cook Station, MO 65449
Voice: 573-265-7445 FAX: 573-265-5052