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
primary care physician
Name
Phone

Area CodePhone Number
medical history
Any medical condition we should be concern about?
If yes, please describe:
Are you currently under a doctor’s care?
If yes, please describe:
Do you have any allergies?
If yes, please describe:
Are you currently taking any medications (prescription and/or over-the-counter)?

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...