Summer Camp Physical Form
Participant Information
Participant Name
First Name
Last Name
Age
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
School Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Information
Name 1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Name 2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Emergency Contact Information
Emergency Contact Person
*
Health/Medical Insurance
Company Name
Policy Number
Policy Name
Health/Medical Information
Weight (kg)
Height (cm)
Assessment
Rows
Status
Description
EENT
Normal
Abnormal
Heart
Normal
Abnormal
Chest
Normal
Abnormal
Lungs
Normal
Abnormal
Reproductive
Normal
Abnormal
Neurological
Normal
Abnormal
Skin
Normal
Abnormal
Bones
Normal
Abnormal
Are you (participant camper) currently taking any medications? If yes, please list them below:
Does the participant need asthma inhaler?
Yes
No
Does the client have any allergies? If yes, please list them below:
Was the participant previously hospitalized? If yes, please indicate when and why:
Did the participant undergo any surgery in the past? If yes, please indicate the name or location of the surgical procedure:
Does the participant wear any implantable medical devices? If yes, what are these devices?
Does the family have a family history of the following medical diagnosis?
Cardiovascular disease
Diabeter Mellitus
Cancer
Asthma
Arthritis
Other
Does the participant have any of the following conditions:
Asthma
Seizures
GI Disorders
Cardiovascular problems
Bone issues
Ear infections
Learning disability
Other
Immunization History
Immunizations
Rows
Vaccinated?
When?
Scheduled Booster
Measles
Yes
No
Mumps
Yes
No
Pertusis
Yes
No
Rublella
Yes
No
Polio
Yes
No
Tetanus
Yes
No
HIB
Yes
No
Hepatitis B
Yes
No
Diptheria
Yes
No
Chickenpox
Yes
No
Acknowledgment and Release
I authorize ABC Camp to provide medical treatment performed by the medical staff in the camp if required.
I authorize ABC Camp to carry out emergency measures like first aid, CPR, and medications as needed.
I release ABC Camp for any liability, damage, or cost that can happen like accidents or injuries during the summer camp.
Parent/Guardian Signature
Submit
Should be Empty: