Trout Unlimited
Tri-State Conservation & Fishing Camp
MEDICAL HISTORY FORM

This is the second part of your application to attend the Trout Unlimited Tri-State Conservation and Fishing Camp. You will need to submit separately both the Campers Information Form and this Medical History Form for your application to be complete.
This Medical History Form must be completed by a parent or guardian of the camper applying.  
All medical or health information that camp staff should know about your camper applicant must be reported on this form.  Campers will be expected to fully participate daily in moderately challenging physical activities, including mountain hiking, wading in rocky mountain streams, and a variety of fishing outings, frequently in summer heat.  Information given on this form will help keep your son or daughter safe and healthy, if they are selected to attend the camp.

EMERGENCY CONTACT INFORMATION – If your son or daughter is selected to attend the camp, and there is an emergency, camp staff will try to reach you by phone. In the space below, please give us emergency contact information for one or more adults:
 NameRelationshipPhone number(s)
Parent or guardian
Parent or guardian
Other emergency contact

PRESCRIPTION MEDICATIONS – ALL prescription medications that camper, if selected, would need to take during the camp must be reported on this Medical History Form, and the medications must be turned over to the Camp Registered Nurse at check-in registration on the first day of camp.  During the camp, the Camp Registered Nurse would dispense the medications to the camper as prescribed by their physician.  Any camper using a prescribed medication for concentration and/or behavior at school must continue to take the medication during camp.

    
Would camper need to take any prescription medication(s) during camp?

If yes, please complete the following:
Would camper need to take any prescription medication(s) during camp?
Yes____ No____
If yes, complete the following: prescription medication(s) required to be taken by camper are:
   Prescription medication(s) required to be taken by camper are:
If additional prescription medications would need to be taken at camp by the applicant, send us
a separate email to medications@tucamp.org with that information and the applicant’s name.
If additional prescription medications would need to be taken at camp by the applicant, send us
a separate email to info@tucamp.org with that information and the applicant’s name.
SPECIAL DIET
     Would camper need to be 
     on a special diet while at camp?
     If yes, explain:
ALLERGIES
     Does camper have any allergies
     camp staff should know about?
     If yes, explain:
ASTHMA
     Does camper have a                
     history of asthma?
     If yes, explain:

  TETANUS BOOSTER VACCINATION
       Date of last tetanus booster shot:

OTHER MEDICAL OR HEALTH CONCERNS
     If there are other medical or health 
     concerns that camp staff should know 
     about, please explain:
      Name of Parent or Guardian of Camper Applicant
      Please give full name
Press the SUBMIT button below to send in this form. You will receive an email
from TU Camp within several days to confirm that your form has been received.
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