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Roanoke County Health History Form

  1. Check all the camps or programs in which this child will participate:

  2. Does the participant have an illness, medical condition or physical/developmental disability?*

  3. Is the participant currently taking any medication?*

  4. Does the participant have any food allergies?*

  5. Does the participant use an Epi Pen?*

  6. Does the participant use an inhaler?*

  7. Does the participant have Diabetes or a related disease?*

  8. Does the participant use insulin?*

  9. Does the participant have a history of heart related problems, or another serious condition?*

  10. Has the participant had a tetanus shot within the last five years?*

  11. Are all other vaccinations current?*

  12. Is English the participant's primary language?*

  13. Has the participant had a physical exam in the last 24 months by a licensed physician?*

  14. Have you checked your child and found them to be lice free?*

  15. By checking this box, I do hereby agree to participate in or allow myself and the individuals in my family to participate in activities offered by Roanoke County Parks, Recreation and Tourism. I assume all risks and liability that may arise from my or my child’s involvement and participation in this activity. I understand that this activity carries the possibility of physical injury and may involve physical activity that may be strenuous and there are risks inherent in this recreational activity. Nothing contained herein shall be construed to grant an expressed or implied warranty of safety. I further understand that Roanoke County and its officers, agents and volunteers are not liable for any injury that may result from the negligence of persons operating this facility. I hereby give permission for Roanoke County staff to provide basic First Aid and seek emergency medical treatment including the ordering of x-rays and routine tests. I give permission for staff to arrange the necessary medical transportation needed. I authorize emergency personnel to treat me or my child in the case of an emergency. In the instance of non-traumatic injury or medical emergency, the participant will be taken to the closest hospital.*

  16. In accordance with section 8.01-40 of the Code of Virginia, I hereby give permission to be photographed and give the department permission to distribute such photographs and identification.*

  17. The final questions on this form are for Camp Roanoke participants only. Which Camp Roanoke program does your child plan to attend this year?*

  18. Has your camper had a previous camp experience?*

  19. Check all the characteristics that apply:*

  20. Does your camper make friends easily?*

  21. Your camper's attitude in regard to cooperation is:*

  22. Your camper's appreciation of the outdoors and nature is:*

  23. How does your camper deal with peer relationships, group living, etc?*

  24. Does your camper want to come to camp?*

  25. I have read and understand Camp Roanoke's policies. I also understand that my registration is not finalized until my initial deposit is made.*

  26. FOR DISCOVERY DAY CAMPERS ONLY - Free pick-up and drop-off is available from Tanglewood Mall. Please check the transportation method your child will be using.

  27. On Friday morning, we will start the day at Splash Valley Water Park. Since you have chosen drop-off by PERSONAL transportation, please choose one of the following options for Friday morning ONLY:

  28. Leave This Blank:

  29. This field is not part of the form submission.