Medical Form

Medical Form

In case of emergency Chv”sh we need to be aware of any medical information. This will be kept completely confidential.
- Full Legal Name*
  
  First NameLast Name
- Date of Birth*
  
  MonthDayYear
  Date
- Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Home Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Mother's Information*
- Preferred Emergency Contact*
- Doctor*
- Do you have any physical health medical history we should be aware of, if yes please specify:*
- Do you have any mental health medical history we should be aware of, if yes please specify: *
- Are you currently on any medication/inhaler, if yes please specify:*
- Are you allergic to any foods, medication or other, if yes please specify: *
  If you carry an epipen please note it here so we can speak to you about it regarding any concerns
- Please note the date of your last tetanus shot*
  
  MonthDayYear
  Date
- Please check off any conditions that apply to you:
  
  AsthmaHeart conditionDiabeticSurgery in the last yearInjury in the last yearAnxiety
- If there is anything else we should be aware of please state it here: *
- PLEASE NOTE: IF YOU ARE ACCEPTED TO CAMP YEKA GIRLS AS A STAFF MEMBER YOU WILL NEED TO SUBMIT THIS FORM A SECOND TIME WITH A SIGNATURE FROM YOUR DOCTOR.
- I undertake to update any information that changes prior to camp. In a case of emergency, I (the undersigned) authorize Menucha Hanoka to relate the above mentioned information as deemed necessary. *
- Name*
- Date*
  
  MonthDayYear
  Date
- Legal Guardian's Signature (for under 18’s only)
  
  I am under 18
- Legal Guardian's Info
- Legal Guardian's Signature
- Should be Empty: