Summer Camp Medical Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

In Case of Emergency

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home phone

Area CodePhone Number

Work phone

Area CodePhone Number

General Medical History

Is the Camp up-to-date all immunizations?

YesNo

Attach immunization record or waiver

Browse Files

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

Date

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

YesNo

Alergies? Check all that apply

FoodMedicationEnvironmental

Please list and explain any allergies

Have you had the Hepatitis B vaccination*

YesNo

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

Chicken Pox (Varicella):

ImmuneNot Immune

Measles:

ImmuneNot Immune

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

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

Is any medication required?

YesNo

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?

YesNo

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

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 CodeCountry

Policy Number:

Expiry Date:

DayMonthYear

Physical Examination

Height:

Weight: