Form
Camp Participant Medical Form
This medical form must be completed for each camp participant and signed by a parent/guardian. Please return no later than two weeks before the start of camp. Participants will not be allowed to attend camp without this completed form. Only one form is necessary regardless of how many camps the participant is attending during the summer of 2024. A new form must be completed each year.
Participant's Name
*
First Name
Last Name
Participant's Date of Birth
*
-
Month
-
Day
Year
Date
Sex:
*
M
F
Height
*
Weight
*
Parent/Guardian Information
Parent/Guardian's Name
*
First Name
Last Name
Parent/Guardian's Email
*
example@example.com
Parent/Guardian's Phone Number
*
Please enter a valid phone number.
Emergency Contact Information
Emergency Contact Name for During Camp
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
2nd Emergency Contact Phone Number
*
Please enter a valid phone number.
Recent Exam Information
Date of Recent Exam
*
-
Month
-
Day
Year
Note: Most recent exam must be within two years.
Physician's Name
*
First Name
Last Name
Physician's Complete Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician's Phone Number
*
Please enter a valid phone number.
Has the participant been treated for any medical problems in the following areas?
Seizures?
*
Yes
No
Length of seizure:
*
Does the participant need to carry a seizure rescue therapy medicine in case of a seizure onset?
*
Yes
No
Any restrictions?
*
Cardiovascular?
*
Yes
No
Any restrictions?
*
Orthopedic Observations?
*
Yes
No
Any restrictions?
*
Pulmonary?
*
Yes
No
Any restrictions?
*
Asthma?
*
Yes
No
Medications and/or inhaler?
*
Any limitations with sight or hearing?
*
Yes
No
Does the participant wear corrective lenses?
*
Yes
No
Does the participant have any contagious or infectious diseases?
*
Yes
No
Please explain:
*
Has the participant been exposed to any contagious or infectious diseases in the past 6 months?
*
Yes
No
Please explain, and please be specific:
*
Allergies
Has the participant had any allergic reactions to the following? If yes, please list a specific and detailed reaction.
Known medicine or drug allergy?
*
Yes
No
Specific medicine and/or drug and detailed reaction for each:
*
Insect bites or stings?
*
Yes
No
Specific insects and detailed reaction for each bite and/or sting:
*
Foods?
*
Yes
No
Specific foods and detailed reaction for each:
*
Any other allergies not covered elsewhere?
*
Yes
No
Specific item and detailed reaction for each:
*
Does the participant need to carry an epinephrine pen for any allergies??
*
Yes
No
Which allergy?
*
Medication
Please list all medication the participant is currently taking (or upload a current medication list for the participant.
Upload a medication list:
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Additional Information & Disclosure
Please describe any other conditions about which program staff should be aware, including social and/or emotional needs:
MEDICAL TREATMENT
*
Parent/Guardian Signature
*
Continue
Continue
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