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

Is the Camp up-to-date all immunizations?

Attach immunization record or waiver

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

Date

Does your child have any food, medication or environmental allergies?

Alergies? Check all that apply

Please list and explain any allergies

Have you had the Hepatitis B vaccination

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

Chicken Pox (Varicella):

Measles:

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

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

Is any medication required?

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?

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

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: