Medical Form This form must be completed to administer medications during the retreat including prescriptions, over-the-counter medications, or supplements. Step 1 of 4 25% EmailThis field is for validation purposes and should be left unchanged.Please note. The url for this page is not valid. Please use the url link provided in the email sent to the registration email address. Wisconsin state law requires us to have a health form for each camper. This form must be completed by a parent or guardian. The information on this form will only be used by Phantom Ranch Health Staff and Health Care providers. If you do not have any information for a field, please leave it empty.Camper Name(Required) First Last Sex Male Female Birthdate MM slash DD slash YYYY MedicationsPlease list the medications, dose, and time of day, or list if the medication is given only as needed. All medication must be in the original packaging. All medication, including; prescriptions, over the counter meds, and supplements must be turned into the Health Supervisor.MedicationDosageFrequencyTime Add RemoveUse the ‘Circle + ‘ button on the right of each medication row to add rowsMedication NotesPlease enter any extra notes regarding any of the above listed medications or supplements.Health ConditionPlease list any current health or medical issues.Insurance Provider InformationIf available, please enter your current insurance information, including insurance provider, and insurance number. Medical Provider InformationIf available, please enter your current medical provider, including Drs name, office name, contact number,. List Food Allergies and Diet RestrictionsPlease describe any food allergies and possible treatment needed.Camper Height and WeightThis information is required by state regulation. This information is required by state regulation. It is required to provide this information on our printed medical sheet for health care providers.Medical DevicesPlease list devices such as glasses, retainers, etc. This information is required by state regulation. It is required to provide this information on our printed medical sheet for health care providers.Medication AllergiesPlease describe non-food related medication allergies and treatment needed (i.e. Bee Stings – EPI pen)Additional comments for doctors or other advanced health care providers.In the event we cannot contact a parent or emergency contact, and your child is in need of emergency care, please add any other comments a doctor may need to know.Please enter immunizationsThis information is required by state regulation. This information is required by state regulation. It is required to provide this information on our printed medical sheet for health care providers. Medical Consent(Required)Required by State Law The person who submitted this form is a parent, legal guardian, or otherwise authorized to submit the form. The information on this form is true to the best of my knowledge and the above named person is in good health and may attend camp. I hereby give my permission to the camp to authorize routine medical or surgical treatment to my child if it should become necessary. I realize that all attempts will be made to notify the parents first. Permission to Authorize Medical or Surgical TreatmentThis form is submitted by:(Required)Please enter full name and relationship to the camper.Phone Number(Required)Email(Required) The Camp Infirmary operates under Standing Medical Orders of a physician. These orders specify which over-the-counter medications the health supervisor (nurse) is allowed to administer. These over-the-counter medications include pain relievers, allergy medications, cold medications, stomach medications, among others and are kept in supply in the camp infirmary. Phantom Ranch cannot accept over-the-counter medications from you to be administered to your child while at camp, we will provide the necessary medication as provided in the Standing Orders.
