# Medical and allergy form

Source: https://backpr.com/resources/templates/medical-and-allergy-form. Last updated: 2026-10-19.

Collects the allergy, medication and medical details staff need, plus emergency contacts and consent for emergency care.

Free download: PDF https://backpr.com/media/templates/backpr-medical-and-allergy-form.pdf · Word https://backpr.com/media/templates/backpr-medical-and-allergy-form.docx · Spanish PDF https://backpr.com/media/templates/backpr-medical-and-allergy-form-es.pdf

> Please fill out one form for each child, and tell us right away if anything changes.

**Child**
- Full name: ______
- Date of birth: ______
- Program and days: ______
- Parent or guardian name and phone: ______

**Allergies**
- Food allergies and reactions: ______
- Other allergies (insect stings, medications, latex) and reactions: ______
- Epinephrine auto-injector (EpiPen) needed? Will it come to the program every day?: ______
- Can your child use it on their own, or will staff hold it?: ______

**Medications**
- Medication, dose and times: ______
- Medication, dose and times: ______
- Medications staff will give during the program (we may ask you and your child's doctor to sign our medication form): ______

**Medical conditions**
- Conditions staff should know about (such as asthma, diabetes or seizures): ______
- What staff should do if symptoms appear: ______

**Other needs**
- Dietary needs: ______
- Behavioral, learning or sensory needs (and what helps your child): ______

**Doctor and insurance**
- Doctor's name and phone: ______
- Health insurance company and policy or member ID: ______

**Health records**
- [ ] Immunization record or physical exam attached (if the program asks for it)

**Emergency contacts**
- Name, relationship, phone: ______
- Name, relationship, phone: ______

**Consent for emergency care**
In an emergency, staff will call 911 if needed and contact me as soon as they can. If they can't reach me, I authorize program staff to get emergency medical care for my child, including ambulance transport and treatment by a doctor or hospital, and to share this form with the medical staff who treat my child.
- Parent or guardian's printed name: ______
- Parent or guardian signature: ______
- Date: ______

### How to use it
- Review every form before the first day and share allergy and medical alerts with the staff who need them.
- Keep emergency medicine and this form together on field trips.
- Ask families to tell you right away when anything changes.
- Check your state's licensing rules on medication and health records.

**What should a camp medical form include?**
Allergies and reactions, medications, medical conditions, what staff should do if symptoms appear, doctor and insurance details, emergency contacts and signed consent for emergency care.

**Can staff give medicine with just this form?**
Many states require a separate medication authorization signed by a parent, and sometimes a doctor, before staff give any medicine. Check your state's rules and use our medication administration log to record each dose.

Free to use and change, but not legal or medical advice. Check your state's licensing rules and your insurer's requirements, and have a lawyer review any consent or waiver language.