Summer Camp Medical Form

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Birth Date

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

In Case of Emergency

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home phone

Format: (000) 000-0000.

Work phone

Format: (000) 000-0000.

General Medical History

YesNo

Attach immunization record or waiver

Date of Last Tetanus or Diptheria, Tetanus, Pertussis(DTaP) Vaccine?

Date

YesNo

FoodMedicationEnvironmental

Please list and explain any allergies

YesNo

Immunity information (please note: this information must be provided prior to employment or you will not be allowed to work):

ImmuneNot Immune

Significant Medical History (surgery, injuries, serious illness):

List any Medical Problems (asthma, seizures, headaches):

YesNo

List any medication taken regularly:

YesNo

Please describe

YesNo

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:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policy Number:

Expiry Date:

Date

Physical Examination

Height:

Weight: