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ATU Summer Camper Health Form
Arkansas Tech University Health & Wellness Center
1605 Coliseum Drive
Doc Bryan Student Services Building, Suite 119
Russellville, AR 72801
(479) 968-0329
hwc@atu.edu
CAMPER INFORMATION
Camper First Name
Camper Middle Name
Camper Last Name
Email Address
Birthdate
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Sex
Sex
M
F
Race:
Which camp are you attending?
Date(s) of Camp
PARENT/GUARDIAN INFORMATION
Parent/Guardian First Name
Parent/Guardian Last Name
Parent/Guardian Contact Phone Number
Parent/Guardian Email
EMERGENCY CONTACTS
Emergency Contact Name and Phone Number
(parent/guardian)
Relationship of Emergency Contact to Camper
Alternate Emergency Contact Name and Phone Number
(i.e. grandparent, aunt, uncle, family friend)
in case the parent/guardian cannot be reached
Relationship of Alternate Emergency Contact to Camper
Secondary Alternate Emergency Contact
(i.e. grandparent, aunt, uncle, family friend)
in case the parent/guardian cannot be reached
Relationship of Secondary Emergency Contact to Camper
CAMPER MEDICAL INFORMATION
Conditions Currently Being Treated or Followed
Surgeries/Hospitalizations/Serious Injuries/Disabilities
Current Medications (
please include over-the-counter and herbal
)
CAMPER MEDICAL HISTORY
ALLERGIES TO MEDICATIONS
Yes
No
Please list details here. Enter "N/A" if none.
BLOOD DISORDERS
Yes
No
Please list details here. Enter "N/A" if none.
CANCER
Yes
No
Please list details here. Enter "N/A" if none.
DIABETES
Yes
No
Please list details here. Enter "N/A" if none.
GASTROINTESTINAL PROBLEMS
(e.g., colitis, hepatitis, ulcers, etc.)
Yes
No
Please list details here. Enter "N/A" if none.
HEART DISEASE
Yes
No
Please list details here. Enter "N/A" if none.
HIGH BLOOD PRESSURE
Yes
No
Please list details here. Enter "N/A" if none.
KIDNEY/BLADDER PROBLEMS
Yes
No
Please list details here. Enter "N/A" if none.
MENTAL HEALTH PROBLEMS
(e.g., anxiety, depression)
Yes
No
Please list details here. Enter "N/A" if none.
RESPIRATORY DISEASE
(e.g., asthma, emphysema)
Yes
No
Please list details here. Enter "N/A" if none.
SEIZURE/EPILEPSY
Yes
No
Please list details here. Enter "N/A" if none.
SKIN PROBLEMS
Yes
No
Please list details here. Enter "N/A" if none.
STROKE
Yes
No
Please list details here. Enter "N/A" if none.
THYROID DISEASE
Yes
No
Please list details here. Enter "N/A" if none.
TUBERCULOSIS
Yes
No
Please list details here. Enter "N/A" if none.
POSITIVE TUBERCULIN SKIN TEST
Yes
No
Please list details here. Enter "N/A" if none.
OTHER MEDICAL PROBLEMS
Yes
No
Please list details here. Enter "N/A" if none.
COMMENTS:
DO YOU HAVE HEALTH INSURANCE?
Yes
No
OVER-THE-COUNTER MEDICATION RELEASE
The ATU Health and Wellness Center has most over-the-counter medications available. Please complete the following information. Medication
will not
be dispensed to campers without parental permission.
(Please select your preference and inital below.)
The ATU Health and Wellness Center has most over-the-counter medications available. Please complete the following information. Medication
will not
be dispensed to campers without parental permission.
(Please select your preference and inital below.)
DO NOT give my child over-the-counter medications.
YES you may provide over-the-counter medications WITHOUT a phone call to parent/guardian.
YES, but only after contacting parent/guardian:
Parent/Guardian Contact #:
By entering my initials, I agree that this acts as my electronic signature and that I have carefully read the above options before selecting my preference.
AUTHORIZATION FOR MEDICAL SERVICES
Permission is hereby granted to the Health and Wellness Center at Arkansas Tech University to authorize medical services. In case of emergency, the Health and Wellness Center is authorized and requested to refer the student to a duly licensed physician, dentist, or hospital, and such physician, dentist, or hospital is authorized to administer such treatment or surgery as appears prudent under the circumstances then existing.
(
*NOTE:
During the summer (June 1st through July 31st), the Health and Wellness Center is staffed with one nurse practitioner and registered nurses. There is no physician on-site.
If it is not an emergency and your child requires more than basic first aid or authorized over-the-counter medications, a Health and Wellness Staff member will always attempt to contact the parent/guardian prior to providing any interventions.
If your child is diagnosed with a contagious illness, per CDC guidelines, it will be recommended that your child go home.
Please make sure that you have made arrangements for this potential situation and someone is available to pick them up.
SIGNATURE OF PARENT/GUARDIAN
(By submitting my electronic signature, I certify that all provided information is accurate and I agree to all terms outlined herein).
Click to Sign...
Date
Submit
