CEC Medical Form 2022

Medical Form
Select the camp(s) you are attending *

UPenn June 24-26, 2022 UPenn July 22-24, 2022
Camper Name *

First Name Last Name
Camper Email *
(*must use same email you registered with*)
Camper Date of Birth *

Month Day Year
Parent/Guardian E-mail *
(*must use same email you registered with*)
Insurance Information
Insurance Company Name *
Policy Number *
Plan Type *
Co-Payment (if applicable)
Emergency Contact

If parent/guardian is not available in an emergency, notify:
Name *

First Name Last Name
Relationship to participant *
Contact Number *

Area Code Phone Number
Health History

Please fill out if applicable:
Do you have?

Heart Problems Asthma Diabetes
Allergies, Operations, serious illness or injuries (provide info & dates):
Are you on Medications? (list all)
Parent's Authorization

The health history completed is correct and to the best of my knowledge. The person here-in described has permission to engage in all camp activities. In the event that I, or persons named above in case of emergency cannot be reached in an emergency, I hereby give my permission to the physician selected by the camp director to hospitalize and/or administer proper medical treatment for my child as named above. I also understand that I will be held responsible for the payment of my child's medical bills.

I AGREE THE ELECTRONIC SIGNATURE BELOW WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Parent/Guardian Electronic signature *

First Name Last Name
Today's Date *

Month Day Year
Should be Empty:

Medical Form

Insurance Information

Emergency Contact

Health History