Benton Day Camp Adult Health History & OTC Meds

1

Name:* This field is required.

First Name

Last Name

2

Birthdate* This field is required.

Date

3

Sex* This field is required.

4

Current Age* This field is required.

5

Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

6

Primary Phone* This field is required.

Example: ###-###-####

7

Secondary Phone

8

Email* This field is required.

example@example.com

9

Family Medical / Hospital Insurance Carrier* This field is required.

10

Policy or Group #* This field is required.

11

Emergency Contact #1* This field is required.

First Name

Last Name

12

Relationship* This field is required.Emergency Contact #1

13

Daytime Phone* This field is required.Emergency Contact #1

Example: ###-###-####

14

Evening Phone* This field is required.Emergency Contact #1

15

Emergency Contact #2* This field is required.

First Name

Last Name

16

Relationship* This field is required.Emergency Contact #2

17

Daytime Phone* This field is required.Emergency Contact #2

Example: ###-###-####

18

Evening Phone* This field is required.Emergency Contact #2

20

Explain any checked boxesfor Chronic or Recurring Illnesses

21

Any restrictions concerning physical activities?* This field is required.

No

Yes

22

Please describe any conditionsregarding restrictions concerning physical activities

23

Allergies

Food, Nuts

Insect Stings

Medicine / Drugs

Other

24

Explain any checked boxesregarding Allergies

25

Special Dietary Restrictions?

26

Tetanus -- Date of shot or last booster (year)* This field is required.

Year

27

Please list any medications taken on a daily basis, including over-the-counter medications.

28

Any other relevant health concerns

29

ADULT

By entering my name below, I verify that this health history is complete and accurate. I am able to engage in all prescribed activities, except as noted.

30

Signature* This field is required.

Clear

31

Signature* This field is required.Printed Signature

First Name

Last Name

32

Today's Date* This field is required.for Electronic Signature

Date

33

Thank you for completing the Benton Day Camp 2024 Health History & OTC Medications Form.