Medical Form
Fill out your medical information carefully
Name
First Name Last Name
Phone Number
Area Code Phone Number
Birth Date
Month Day Year
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
In Case of Emergency
Name
First Name Last Name
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Home phone
Area Code Phone Number
Work phone
Area Code Phone Number
General Medical History
Is the Camper up-to-date all immunizations?
Yes No
Attach immunization record or waiver
Browse Files
Cancelof
Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?
Month Day Year
Date
Does your child have any food, medication or environmental allergies?
Yes No
Alergies? Check all that apply
Food Medication Environmental
Please list and explain any allergies
Chicken Pox (Varicella):
Immune Not Immune
Measles:
Immune Not Immune
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
Is any medication required?
Yes No
List any medication taken regularly:
In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate?
Yes No
Please describe
In the event that the child care program must be evacuated, are there medications or supplies that must be taken with this child
Yes No
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 Insured
Name of Insurance Company:
Address
Street Address
Street Address Line 2
City State / Province
Postal / Zip Code Country
Policy Number:
Expiry Date:Type a question
Day Month Year
Seeds of Joy
Preschool Summer Camp
Should be Empty:

Medical Form

In Case of Emergency

General Medical History

Medical insurance details

Seeds of Joy