Hi-Five Summer Camp Medical Form

Medical Form

Fill out your medical information carefully
Child's Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Child's Birth Date

MonthDayYear
Child's grade in the Fall*

Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade (CIT)9th Grade (CIT)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In Case of Emergency
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
General Medical History
Is the Camp up-to-date all immunizations?*

YesNo
Attach immunization record from doctor or school form from doctor*

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

YesNo
Alergies? Check all that apply

FoodMedicationEnvironmental
Please list and explain any allergies
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:
Policy Number:
Group Number:
INSURANCE CARD

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WEEKS ATTENDING

Week 1 (6/12-16)Week 2 (6/19-23)Week 3 (6/26-30)Week 4 (7/5-7/7)Week 5 (7/10-14)Week 6 (7/17-21)Week 7 (7/24-28)Week 8 (7/31-8/4)
Should be Empty: