Summer Camp Medical Form

Medical Form

Fill out your medical information carefully
Name

First NameLast Name
Birth Date

MonthDayYear
Gender
Please list the names of your child's friends attending the same camp.
In Case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell phone

Area CodePhone Number
Work phone

Area CodePhone Number
General Medical History
Is the Camp up-to-date all immunizations?
Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does your child have any food, medication or environmental allergies?
Alergies? Check all that apply
Please list and explain any allergies
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
Is any medication required?
List any medication taken regularly:
Please describe
I consent to the following administration: sunscreen - topical product or lotion, exact dosage: liberal application per exposed area, to be administered: before high sun exposure.
Medical insurance details
Name of Insurance Company:
Policy Number:
Expiry Date:

DayMonthYear
Physical Examination
Height:
Weight:
Mom's Email
example@example.com
Mom's Name

First NameLast Name
Please sign here if you have received & reviewed the Camp Rules and Camp Waiver
Should be Empty:

Medical Form