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Camp Jotoni Capital CAMPaign
Donate
EMPLOYMENT OPPORTUNITIES
CAMPER RESOURCES
Camperships

Online Health Form

Health Form

Camp Jotoni Health Form
Please fill out all required fields.
Camper Name*
First Last
Parent / Guardian Email*
Date of Birth*
MM slash DD slash YYYY
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Gender*
- Male
- Female
Health Insurance Information
Is the camper covered by family medical / hospital insurance?*
- Yes
- No
if Yes, please indicate insurance carrier name*
if Yes, please indicate insurance group number*
Upload Copies of insurance cards
Max. file size: 100 MB.
If possible, please upload copies of your insurance cards
Allergy Information
Does Your Camper Have Medication Allergies*
- Yes
- No
If Yes, what medications? Please also list the reaction and treatment*
Does Your Camper Have Food Allergies*
- Yes
- No
If Yes, what medications? Please also list the reaction and treatment*
Does Your Camper Have Other Allergies*
- Yes
- No
If Yes, what medications? Please also list the reaction and treatment*
Over The Counter Medications
Headache / Pain*

Please Indicate the medication and dosage
Diarrhea*

Please Indicate the medication and dosage
Cough*

Please Indicate the medication and dosage
Sore Throat*

Please Indicate the medication and dosage
Congestion*

Please Indicate the medication and dosage
Menstruation Cramps

Please Indicate the medication and dosage
Other

Please Indicate the medication and dosage
General Health Questions
Has Your Camper...
Had any recent illness or infectious disease?*
- Yes
- No
If Yes .. Please explain*
Ever tested Positive For Covid-19*
- Yes
- No
Received The Covid-19 Vaccine*
- Yes
- No
If Yes, Please Upload The Vaccination Card
Max. file size: 100 MB.
Have a chronic or recurring illness/condition?*
- Yes
- No
If Yes .. Please explain*
Ever been hospitalized?*
- Yes
- No
If Yes .. Please explain*
Ever had surgery?*
- Yes
- No
If Yes .. Please explain*
Have frequent headaches?*
- Yes
- No
If Yes .. Please explain*
Ever had a head injury?*
- Yes
- No
If Yes .. Please explain*
Ever been knocked unconscious?*
- Yes
- No
If Yes .. Please explain*
Wear glasses contacts or protective eyewear*
- Yes
- No
Ever had frequent ear infections?*
- Yes
- No
If Yes .. Please explain*
Ever had seizures?*
- Yes
- No
If Yes .. Please explain*
High Blood Pressure?*
- Yes
- No
If Yes .. Please explain*
been diagnosed with heart murmur?*
- Yes
- No
If Yes .. Please explain*
Ever had back problems?*
- Yes
- No
If Yes .. Please explain*
Ever had problems with joints (e.g., knees, ankles)?*
- Yes
- No
If Yes .. Please explain*
Have an orthodontic appliance?*
- Yes
- No
If Yes .. Please explain*
Have any skin problem?*
- Yes
- No
If Yes .. Please explain*
Have diabetes?*
- Yes
- No
If Yes .. Please explain*
Have asthsma?*
- Yes
- No
If Yes .. Please explain*
Had mononuceosis in the past 12 months?*
- Yes
- No
If Yes .. Please explain*
Had chronic problems with diarrhea / constipation?*
- Yes
- No
If Yes .. Please explain*
Have problems with sleepwalking?*
- Yes
- No
If Yes .. Please explain*
Ever had emotional difficulties where professional help was sought?*
- Yes
- No
If Yes .. Please explain*
Please upload immunization records
Max. file size: 100 MB.
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