Camper Physical Examination Form
Camper Information
Camper Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Emergency Contact Number
-
Area Code
Phone Number
Back
Next
This part must be completed by a licensed medical provider.
Physical exam done today
*
Yes
No
Date of last physical
-
Month
-
Day
Year
Date
Weight
*
kgs
Height
*
cm
Immunization History
*
Rows
Dose 1 (Month/Year)
Dose 2 (Month/Year)
Dose 3 (Month/Year)
Dose 4 (Month/Year)
Dose 5 (Month/Year)
Most Recent Dose (Month/Year)
MMR
IPV
DTaP
Tdap
HIB
PCV
Hepatitis B
Hepatitis A
Varicella
Meningococcal B
2vHPV, 4vHPY or 9vHPV
Allergies
*
Foods
Medications
Environmental
None
Other
Please explain all allergies
Diet & Nutrition
*
Yes
No Restrictions
Please explain
Medications
*
Yes
No
Please list
Additional Information
Name of licensed provider
*
First Name
Last Name
Phone Number of licensed provider
*
-
Area Code
Phone Number
Signature of licensed provider
*
Submit
Should be Empty: