23800 Parallel Rd, Tonganoxie, KS 66086

(913) 845-2586

Camp Mount Hermon

Church of the Brethren
Western Plains District

CoB Camper Forms

Health Form

Please print this out and have the camper's guardian and physician fill out and complete. 

Campers need to mail or scan and e-mail the completed form to the director of their camp.

Email and street addresses can be found on the CALENDAR page.

Click HERE for the Health Form


Checklist of Required Documents

Camps in Kansas are regulated like a childcare facility. The State of Kansas requires that we have the following items on file:

1. Online Registration Form (found on CALENDAR page for your camp)

2. Registration Fee Payment (check made out to "Camp Mount Hermon", mailed to your Camp Director, found on the CALENDAR page)

3. Copy of your child's health insurance card (front and back, bring to camp)

4. Health Form:

     Part I

  • Valid up to 12 months
  • Must be SIGNED by health provider
  • Western Plains District Camp Health Form Part II OR a Kansas School Health Form. (If you are not from Kansas, you can use a non-Kansas school health form if it includes all the information that is contained in the Western Plains District Camp Health Form Part II, including a health provider signature.)
  • Your child's current immunization record. (This is part of the Western Plains District Camp Health Form Part II. If using your school's health form, please include a copy of your child's current immunization record)

     Part II

  • Needs to be updated EVERY year​
  • Must be SIGNED by a health provider
  • List of prescribed medications and instructions

What to bring

Click HERE for the Camper's Guide