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Camp Allergy, Medical, and Diet Form

Camper Allergy Medical Form

Please fill complete information on each individual person with an allergy or dietary need.

Name*
First Last
Email
Cell Phone
In case we need to connect at Winter Weekend
Date*
MM slash DD slash YYYY

Please fill in today's date.
Is this Camper a child or an adult
- Child
- Adult
- KC - Kid's Counselor
Child Camper or KC Photo
If this camper is a child or KC, it would be helpful for us to have a photo to attach to their allergy form. Please upload a photo here if you have one.
Accepted file types: jpg, jpeg, png, gif.
Allergies
Allergy/Dietary
Please choose the appropriate box.
- Allergy
- Dietary Needs
- Medical
- All of the above
Camper Medical Condition
Please describe this campers medical condition (i.e. Asthma, Allergy, etc.)
Allergy Alert
This camper has a DANGEROUS, life threatening allergyto the following foods:
Specific Food Allergies
This person has specific allergies to the following foods or ingredients:
Possible Symptoms from this allergy
- flushed face, hives, swelling or itchy lips, tongue, eyes
- tightness in throat, mouth, chest
- difficulty breathing or swallowing, wheezing, coughing, choking
- vomiting, nausea, diarrhea, stomach pains
- dizziness, unsteadiness, sudden fatigue, rapid heartbeat
- loss of consciousness
Other Possible Symptoms not listed above:
Action - Emergency Plan
- use Asthma Inhaler
- use Epipen / Ana-kit immediately!
- have someone call an ambulance and advise the dispatcher that a child is having an anaphylactic reaction.
- if ambulance has not arrived in 10 to 15 minutes and breathing difficulties are present (eg. wheezing, coughing, throat clearing), give a second Epipen, if available.
- even if symptoms subside entirely, this child must be taken to hospital immediately.
- loss of consciousness
Other Action Plans not listed above:
Epipens / Ana-kit are kept
Recommended substitute snacks
Please list possible snacks that this camper can have.
Diet
Diet Situation
Please tell us a little about your diet situation.
Special Diet Needs
Please check any special diet needs that apply to you.
- non-celiac gluten free
- egg free
- dairy free
- vegan
- vegetarian
- diabetic
Please add any other special diet needs here.

If you have more than one person in your family with medical, allergy or dietary needs, please click on the button below and fill out a new form for them.

Return to Allergy Needs Form
Return to Summer Splash Page

Winter Weekend

Winter Weekend Registration
Winter Weekend Family Camp
Winter Weekend KC Application
Winter Weekend Kid’s Counselors (KC) Program
Winter Weekend Speakers
- Camp Allergy & Diet Form
Grand View Lodge
Directions to GVL
Winter Weekend Sample Schedule

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