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Health History and Emergency Care Plan
This form is required for each camper by the Department of Children and Families.  Please fill out a form for each child separately!

  Camper Name: [Last, First]

  Telephone Number Birthdate (mm/dd/yyyy)
  First Day of Camp
  Parent 1 Home Phone
  Work Phone Cell Phone 
  Parent 2 Home Phone
  Work Phone Cell Phone
  Physician Physician's Phone
  Physician's Address



Sunscreen and Insect Repellent Authorization
If provided by the parent, the sunscreen or insect repellent shall be labeled with the child's name.
  Please Note:  CGI provides 30spf sunscreen only - if you prefer a higher strength, you must provide your own.

  Yes No 
I authorize CGI to apply sunscreen to my child

Sunscreen Brand Name:

  Yes No 
I authorize CGI to allow my child to self-apply sunscreen

Sunscreen Strength:

  Yes No 
I authorize CGI to apply repellent to my child

Insect Repellent Brand Name:

  Yes No 
I authorize CGI to allow my child to self-apply repellent

Insect Repellent Strength:

1. Check any special medical condion that your child may have:

No specific medial condition



Epilepsy/seizure disorder

Cerebral Palsy/motor disorder

Any disorder including Cognitively Disables, LD, ADD, ADHA, or Autism


Gastrointestinal or feeding concerns including speical diet and supplements

Other condition(s) requiring special care; please specify:

Milk allergy - See Side Note* *If child is allergic to milk, please attach a statement from the medical professional indicating the acceptable alternative.

Food allergies- Specify food(s)

Non-food allergies - Specify
2. Triggers that may cause problems - Specify.
3. Signs and symptoms to watch for - Specify.
4. Steps the child care provider should follow.  If prescription or non-prescription medications are necessary, a copy of the from Authorization to Administer Medication should filed with CGI. 
5. Identify any child care staff to whom you have given specialized training/instruction to help treat symptoms.
6. When to call parents regarding symptoms or failure to respond to treatment.
7. When to consider that the condition requires emergency medical are or reassessment.
8. Additional information that may be helpful to the child care provider.
  By typing my name and the date below, I certify that the information on this application is true and correct:
  Name:      Date:


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Camp Gan Israel • Milwaukee, WI 53217 • 414-228-8372
A branch of the world's largest Jewish Camping network, Camp Gan Israel International

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