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Roanoke County Health History Form
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
Please DO NOT sign or create an account to use this form. www.RoanokeCountyParks.com does not utilize this feature.
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.
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.
Download a Printable Version of This Form
Roanoke County 2022 Health Form
Participant Last Name
*
Participant First Name
*
Middle Initial
*
Participant Gender
*
-- Select One --
Male
Female
Date of Birth
*
School Attending
*
Grade (as of August 2022)
*
Street Address
*
City
*
State
*
Zip Code
*
Primary Phone
*
Main Contact's e-mail
*
Check all the camps or programs in which this child will participate:
Camp Roanoke - Any Program
Explore Park - Any Program
After School for Kids (on-site after school program at elementary schools)
Athletics / Sports programs
Full Day Summer Camps at Green Ridge and Cave Spring Elementary School
Pre-K Day Camps at Brambleton & Green Ridge
PARENT / GUARDIAN INFORMATION
Guardian 1 Name
*
Guardian 1 Date of Birth
*
Employer
*
Guardian 1 Primary Phone
*
Guardian 1 Seconday Phone
Guardian 2 Name
Guardian 2 Date of Birth
Guardian 2 Employer
Guardian 2 Primary Phone
Guardian 2 Secondary Phone
HEALTH / MEDICAL HISTORY
Does the participant have an illness, medical condition or physical/developmental disability?
*
Yes
No
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.
Is the participant currently taking any medication?
*
Yes
No
If YES, please list the medications and to what extent they will impact your child's participation or physical abilities.
Does the participant have any food allergies?
*
Yes
No
If YES, please explain.
Does the participant use an Epi Pen?
*
Yes
No
Does the participant use an inhaler?
*
Yes
No
Does the participant have Diabetes or a related disease?
*
Yes
No
Does the participant use insulin?
*
Yes
No
Does the participant have a history of heart related problems, or another serious condition?
*
Yes
No
If YES, please explain.
Has the participant had a tetanus shot within the last five years?
*
Yes
No
Are all other vaccinations current?
*
Yes
No
If NO, please explain.
Please list any dietary restrictions:
Is English the participant's primary language?
*
Yes
No
Please describe the participant's swimming ability:
*
-- Select One --
Non Swimmer
Beginning Swimmer
Intermediate Swimmer
Advanced Swimer
Primary Doctor or practice:
*
Doctor's phone:
*
Have you checked your child and found them to be lice free?
*
Yes
No
PLEASE NOTE: Lice will exclude participant upon detection, and refunds will not be issued.
WAIVER / PERMISSION TO TREAT AND TRANSPORT
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.
*
I Agree
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.
*
Yes
No
EMERGENCY CONTACTS and AUTHORIZED PICKUPS
Contact/Pickup1
*
Relationship
*
Primary Phone
*
Work Phone
*
Contact 1 Address
*
City
*
State
*
Zip Code
*
Contact/Pickup2
Relationship
Primary Phone
Work Phone
Contact 2 Address
City
State
Zip Code
Please list any persons NOT eligible for camper pick-up and visitation. Legal documentation is required two weeks prior to program start date.
For additional emergency contacts, please submit a separate document, or email your program's main contact.
Has your camper had a previous camp experience?
*
Yes
No
If YES, when and where?
What are your camper's talents or hobbies?
*
List adjectives that describe your camper.
*
Check all the characteristics that apply:
*
Active
Aggressive
Athletic
Cooperative
Dependable
Self Conscious
Self Reliant
Selfish
Shy
Show-off
Teasing
Timid
Does your camper make friends easily?
*
Yes
No
Your camper's attitude in regard to cooperation is:
*
Above Average
Below Average
Average
Your camper's appreciation of the outdoors and nature is:
*
Above Average
Below Average
Average
How does your camper deal with peer relationships, group living, etc?
*
Above Average
Below Average
Average
Does your camper want to come to camp?
*
Yes
No
Why or why not?
Date of last tetanus shot:
*
What is your camper looking forward to the most?
What would you like us to help your camper accomplish during their experience at Camp Roanoke?
*
Please provide any additional information you feel would help us understand your camper better (including physical, emotional, medical or educational situations).
Please list the course number for the Camp Roanoke program you plan to enroll in:
*
Not sure which week of camp your child is attending?
Find a list of weeks and course numbers here!
Please read the Camp Roanoke registration information here before completing this form:
Important Policies and Information
I have read and understand Camp Roanoke's policies. I also understand that my registration is not finalized until my initial deposit is made.
*
I have read and understand
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