Health Card #: ______________________________     Week: _____     Cabin: __________

		DORION BIBLE CAMP AND CONFERENCE CENTRE HEALTH FORM

Name: _______________________________  Birthdate: ______________     Age: _________

Address: _____________________________  City: _______________  Postal Code: _______

Parent or Guardian: ______________________________________ Phone #: _______________

In case of emergency contact: ____________________________ Phone #: _______________

	(Their relationship to you: ____________________________)

Family Doctor: _________________________________________  Phone #: ________________

Hospital preferred: _______________________________________________________________

HEALTH HISTORY (indicate year if possible)
_____ Chicken Pox		Please indicate Medication

_____ Measles			_____ Diabetes ______________________________ meds

_____ Mumps			_____ Seizures ______________________________ meds

_____ Whooping Cough		_____ Asthma  _______________________________ meds

_____ Rheumatic Disease		_____ Kidney Problem ________________________ meds

_____ Bronchitis

INDICATE THE FREQUENCY OF THE FOLLOWING:
_____ Sleep Walking		_____ Ear Aches and Infections
_____ Bed Wetting		_____ Sore Throats
_____ Constipation		_____ Sinus Trouble
_____ Headaches			_____ Colds
_____ Fainting Spells		_____ Rashes
ARE THERE ANY OTHER HEALTH COMPLICATIONS WE SHOULD KNOW ABOUT?_____________________

___________________________________________________________________________________
ALLERGIES AND REACTIONS:
Penicillin or other drugs? ________________________________________________________

Insect bites? _____________________________________________________________________

Food or Diet Restrictions?_________________________________________________________

Is Immunization up to date? _______________________________________________________

List any activities which should be restricted:____________________________________

ON THE BACK, PLEASE LIST ANY REGULAR MEDICATION NEEDED: NAME, DOSAGE AND FREQUENCY.

Date of last medical exam: ___________ Parent Signature: _________________________

A doctor's signature is NOT required.