Roanoke County Health History Form

2. Please DO NOT sign or create an account to use this form. www.RoanokeCountyParks.com does not utilize this feature.

4. The following form is required for every participant in Roanoke County's summer camp and after school programs, as well as Camp Roanoke. Your participant's health form is valid from January to December of the year submitted. New health forms must be completed annually. Completing this form does not finalize your program registration. Payment is needed to complete your registration.

6. Please note that this is not a secure web form. While electronic submission is preferred, you may choose to download a printable version of this form by clicking on the link to the right.

7. Download a Printable Version of This Form
   Roanoke County 2019 Health Form

9. Participant Last Name*

10. Participant First Name*

11. Middle Initial*

12. Participant Gender*
    -- Select One --MaleFemale

14. Date of Birth*

15. School Attending*

16. Grade (as of August 2019)*

18. Street Address*

19. City*

20. State*

21. Zip Code*

23. Primary Phone*

24. Main Contact's e-mail*

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

    1. Camp Roanoke - Any Program
    2. Explore Park - Any Program
    3. Ridge Kids (after school program at Green Ridge)
    4. After School for Kids (on-site after school program at elementary schools)
    5. Athletics / Sports programs

    1. Full Day Camps at Green Ridge
    2. Kids in Camp at Penn Forest ES
    3. Half Day Themed Camps (Any Location)
    4. A.C.E. Camp
    5. Snow Day Camps

30. PARENT / GUARDIAN INFORMATION

32. Guardian 1 Name*

33. Guardian 1 Date of Birth*

34. Employer*

36. Guardian 1 Primary Phone*

37. Guardian 1 Seconday Phone

39. Guardian 2 Name

40. Guardian 2 Date of Birth

41. Guardian 2 Employer

43. Guardian 2 Primary Phone

44. Guardian 2 Secondary Phone

48. HEALTH / MEDICAL HISTORY

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

    1. Yes
    2. No

52. If YES, please explain the condition and to what extent it will impact your child's participation or physical abilities. Participants with disabilities are welcome to attend Roanoke County programs, You will be contacted by a staff member to talk about reasonable accommodations or support the participant may need to be successful in the program. This must happen two weeks before the program starts.

54. Is the participant currently taking any medication?*

    1. Yes
    2. No

56. If YES, please list the medications and to what extent they will impact your child's participation or physical abilities.

58. Does the participant have any food allergies?*

    1. Yes
    2. No

60. If YES, please explain.

62. Does the participant use an Epi Pen?*

    1. Yes
    2. No

63. Does the participant use an inhaler?*

    1. Yes
    2. No

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

    1. Yes
    2. No

66. Does the participant use insulin?*

    1. Yes
    2. No

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

    1. Yes
    2. No

70. If YES, please explain.

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

    1. Yes
    2. No

74. Are all other vaccinations current?*

    1. Yes
    2. No

75. If NO, please explain.

77. Please list any dietary restrictions:

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

    1. Yes
    2. No

81. Please describe the participant's swimming ability:*
    -- Select One --Non SwimmerBeginning SwimmerIntermediate SwimmerAdvanced Swimer

83. Primary Doctor or practice:*

84. Doctor's phone:*

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

    1. Yes
    2. No

87. Name of doctor who performed physical:

88. PLEASE NOTE: Residential programs such as Camp Roanoke require a physical within 24-months prior to participation. If you checked "NO", please bring proof of a recent physical with your camper on the first day of camp.

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

    1. Yes
    2. No

91. PLEASE NOTE: Lice will exclude participant upon detection, and refunds will not be issued.

93. WAIVER / PERMISSION TO TREAT AND TRANSPORT

95. 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.*

    1. I Agree

97. 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.*

    1. Yes
    2. No

101. EMERGENCY CONTACTS and AUTHORIZED PICKUPS

103. Contact/Pickup1*

104. Relationship*

105. Primary Phone*

106. Work Phone*

108. Contact 1 Address*

109. City*

110. State*

111. Zip Code*

113. Contact/Pickup2

114. Relationship

115. Primary Phone

116. Work Phone

118. Contact 2 Address

119. City

120. State

121. Zip Code

123. Please list any persons NOT eligible for camper pick-up and visitation. Legal documentation is required two weeks prior to program start date.

125. For additional emergency contacts, please submit a separate document, or email your program's main contact.

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

     1. Discovery (rising K-5 grade)
     2. Explorer (rising 3-4 grade)
     3. Pioneer (rising 5-6 grade)
     4. Voyager (rising 6-7 grade)

     1. Adventure (rising 8-9 grade)
     2. Outpost (rising 9-10 grade)
     3. Trek (rising 9-11 grade)

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

     1. Yes
     2. No

133. If YES, when and where?

135. What is your child's t-shirt size?*
     -- Select One --Youth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult Extra Large

137. What are your camper's talents or hobbies?*

139. List adjectives that describe your camper.*

141. Check all the characteristics that apply:*

     1. Active
     2. Aggressive
     3. Athletic
     4. Cooperative

     1. Dependable
     2. Self Conscious
     3. Self Reliant
     4. Selfish

     1. Shy
     2. Show-off
     3. Teasing
     4. Timid

143. Does your camper make friends easily?*

     1. Yes
     2. No

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

     1. Above Average
     2. Below Average
     3. Average

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

     1. Above Average
     2. Below Average
     3. Average

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

     1. Above Average
     2. Below Average
     3. Average

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

     1. Yes
     2. No

152. Why or why not?

154. Date of last tetanus shot:*

156. What is your camper looking forward to the most?

158. What would you like us to help your camper accomplish during their stay at Camp Roanoke?*

160. Please provide any additional information you feel would help us understand your camper better (including physical, emotional, medical or educational situations).

162. Please list the course number for the Camp Roanoke program you plan to enroll in:*

163. Not sure which week of camp your child is attending?
     Find a list of weeks and course numbers here!

165. Please read the Camp Roanoke registration information here before completing this form:
     Important Policies and Information

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

     1. I have read and understand

169. 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.

     1. Drop-off by BUS at Tanglewood (8:05am-8:20am)
     2. Pick-up by BUS at Tanglewood (4:40pm-4:50pm)
     3. Drop-off at camp by PERSONAL transportation (9:00am)
     4. Pick-up at camp by PERSONAL transportation (4:00pm)

171. 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:

     1. Drop-off at CAMP by personal transportation at 8:30am
     2. Drop-off at SPLASH VALLEY (Green Ridge Recreation Center) by personal transportation at 9:00am

Leave This Blank:


172. 1. Receive an email copy of this form.
173. Email address

     This field is not part of the form submission.

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