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
  2 digit month, 2 digit day, 4 digit yearDate
- 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
  2 digit month, 2 digit day, 4 digit yearDate
- Please check off any conditions that apply to you:
- 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
  2 digit month, 2 digit day, 4 digit yearDate
- Legal Guardian's Signature (for under 18’s only)
- Legal Guardian's Info
- Legal Guardian's Signature
- Should be Empty: