In Action Summer Camp Medical Form

Medical Form

Fill out your medical information carefully
Name

First NameLast Name
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In Case of Emergency
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
General Medical History
Is the Camper up-to-date all immunizations?

YesNo
Attach immunization record or waiver

Browse Files

Cancelof
Does your child have any food, medication or environmental allergies?

YesNo
Alergies? Check all that apply

FoodMedicationEnvironmental
Please list and explain any allergies
Immunity information (please note: this information must be provided prior to employment or you will not be allowed to work):
Significant Medical History (surgery, injuries, serious illness):
List any Medical Problems (asthma, seizures, headaches):
Is any medication required?

YesNo
List any medication taken regularly:
In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate?

YesNo
Please describe
In the event that the child care program must be evacuated, are there medications or supplies that must be taken with this child

YesNo
Medical insurance details
Name of Insurance Company:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Policy Number:
Expiry Date:

DayMonthYear
Should be Empty:

Medical Form

In Case of Emergency

General Medical History

Medical insurance details