Medical And Medication Form

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*

Confirmation Emailname@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone*

Area CodePhone Number
Type of Phone*

MobileHome
primary care physician
Name*
Phone*

Area CodePhone Number
medical history
Any medical condition we should be concern about?*

YesNo
If yes, please describe:
Are you currently under a doctor’s care?*

YesNo
If yes, please describe:
Do you have any allergies?*

YesNo
If yes, please describe:
Are you currently taking any medications (prescription and/or over-the-counter)?*

YesNo

Date of last tetanus shot:

MonthDayYear
Medical Insurance Carrier*
in case of emergency...

Please list three people we may contact.
Emergency Contact #1*

First NameLast Name
Relationship to Emergency Contact #1*
Emergency Contact #1 – Phone*

Area CodePhone Number
Emergency Contact #2*

First NameLast Name
Relationship to Emergency Contact #2*
Emergency Contact #2 – Phone*

Area CodePhone Number
Emergency Contact #3*

First NameLast Name
Relationship to Emergency Contact #3*
Emergency Contact #3 – Phone*

Area CodePhone Number
Signature*
Date

MonthDayYear
During the week of camp, this Medical form is to be enclosed in envelope with your name on it. It will be destroyed by shredding after camp.
Should be Empty:

in case of emergency...