additional information about participant

We would like your child to gain the most from JDI. For us to assist in accomplishing this, it is necessary to have a current health history. Falsifying or failing to disclose information about your health may result in dismissal from the program.

Personal information

contact info

Health history

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Medications being taken

Please list ALL current medications including over-the-counter, non-prescriptions, vitamins and supplements. Bring enough medication to last the entire time at camp. Keep it in the original packaging that identifies the name of the medication, the dosage, and the frequency of administration. ALL medications will be stored in the camp medical center.

Dietary restrictions

Allergic reactions

Please list all of the participant's allergic reactions.

General questions

1. Had any recent injury, illness or infectious disease?
2. Have a chronic or recurring illness?
3. Ever been hospitalized?
4. Ever had a head injury?
5. Ever been knocked unconscious?
6. Wear glasses, contacts?
7. Ever had chest pain during or after exercise?
8. Ever had back problems?
9. Ever had problems with joints (e.g. knees, ankles)?
10. Have any skin problems (itching, rashes, acne)?
11. Have asthma?
12. Had problems with diarrhea/constipation?
13. Have diagnosed eating disorder?
14. Ever had emotional and/or mental difficulties?
If YES, did s/he seek professional help?
If YES, did s/he receive medication?

As the parent/legal guardian to the participant, I hereby declare that the information given in this form is correct and detailed to the best of my knowledge. I agree to notify the camp in writing of any changes prior to the start of the program. I hereby give permission for emergency medical care to take place should it be necessary. hereby give permission for the camper to receive psychological services if necessary. I HEREBY CERTIFY that all statements contained in the Health History Form are true and correct to the best of my knowledge, and further, I AUTHURIZE JDI or any party the JDI authorizes to obtain, or release any information acquired in the course of the participant’s examination or treatment.

In case of failure to provide full information or providing false information, I take full responsibility for the consequences of this decision.

Consent to participate in additional activities:

Consent to use of photo and video materials

In any case, if you believe that the Participant's image has been misused, please contact us at camp@justdilijanit.org, and we will take appropriate actions.

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