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Roanoke County Health History Form

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

  3. 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.
  4. Check all the camps or programs in which this child will participate:
  7. Does the participant have an illness, medical condition or physical/developmental disability?*
  8. Is the participant currently taking any medication?*
  9. Does the participant have any food allergies?*
  10. Does the participant use an Epi Pen?*
  11. Does the participant use an inhaler?*
  12. Does the participant have Diabetes or a related disease?*
  13. Does the participant use insulin?*
  14. Does the participant have a history of heart related problems, or another serious condition?*
  15. Has the participant had a tetanus shot within the last five years?*
  16. Are all other vaccinations current?*
  17. Is English the participant's primary language?*
  18. Have you checked your child and found them to be lice free?*
  19. PLEASE NOTE: Lice will exclude participant upon detection, and refunds will not be issued.
  21. 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.*
  22. 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.*
  23. PLEASE NOTE: Any persons arriving to pick up your child who is NOT on the Pick Up list will be denied pick up until parents are notified and permission is granted.  

    SICKNESS: A child will NOT be allowed to participate in the program with any of the following symptoms: 100 degree fever or higher, sore throat, vomiting, undiagnosed rash, diarrhea or lice. When a child is not feeling well, the parent/guardian or the emergency contact will be notified to pick up your children. 

  25. For additional emergency contacts, please submit a separate document, or email your program's main contact.
  26. Has your camper had a previous camp experience?*
  27. Check all the characteristics that apply:*
  28. Does your camper make friends easily?*
  29. Your camper's attitude in regard to cooperation is:*
  30. Your camper's appreciation of the outdoors and nature is:*
  31. How does your camper deal with peer relationships, group living, etc?*
  32. Does your camper want to come to camp?*
  33. I have read and understand Camp Roanoke's policies. I also understand that my registration is not finalized until my initial deposit is made.*
  34. Leave This Blank:

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