Summer Camp Medical Form

Medical Form

Please fill out a medical form for each camper.
Name

First Name Last Name
Phone Number

Area Code Phone Number
Birth Date

Month Day Year
Medicare Card Number
In Case of Emergency
Contact one name

First Name Last Name
Home phone

Area Code Phone Number
Work phone

Area Code Phone Number
Relationship
Contact two name

First Name Last Name
Home phone

Area Code Phone Number
Work phone

Area Code Phone Number
Relationship
General Medical History
Is the Camper up-to-date all immunizations?

Yes No
Does your child have any food, medication or environmental allergies?

Yes No
Please list and explain any allergies
Does your child have any physical injuries or limitations that the camp staff should be aware of

Yes No
Please explain the physical needs of your child.
Does your child have any behaviour, emotional or intellectual needs that the camp staff should be aware of

Yes No
Please explain the behavioural, emotional or intellectual needs of your child.
Medical History
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
Is any medication required?

Yes No
List any medication taken regularly:
Does your child need to carry an Epi-Pen?

Yes No
In case of an emergency , where an accident takes place within the Camp Artemis programming, I give Phoenix Community Projects and its staff permission to act on my behalf for the care of my child until I am able to be present.

Yes No
Please submit a recent photo of your child here

Browse Files

Cancel of
Confirmation

BY ACKNOWLEDGING AND SUBMITTING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Should be Empty:

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