History Camp Medical Form

Camper's Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Entering Grade

456

Parent/Guardian 1 Parent/Guardian 2

Home Phone

Work Phone

Cell Phone

If not available in emergency, please notify:

Name

Relationship

Phone

Insurance Co

Policy

Policy Holders Name ParentGuardian

Prescription

NonPrescription

Drug Sensitivities/allergies

YESYES/SevereNO

If YES, please list allergies and annotate which one(s) are severe

Epi-Pen: Does your child require an epi-pen to treat an allergy?

YESNO

If YES, my child has been instructed to carry their epipen to all camp activities INITIAL

Asthma: Does your child use an inhaler?

YESNO

If YES, my child has been instructed to carry their inhaler to all camp activities INITIAL

Date of last tetanus

Date

Pre-existing Conditions: Does your child have any injuries or conditions that presently exist that would limit from camp activities?

YESNO

If YES, please describe

Chronic Illness: Has your child been diagnosed with any other significant chronic illness (diabetes, epilepsy, ehart, etc?

YESNO

If YES, please describe

Food Allergies: Does your child have any special dietary considerations or food allergies that would need accommodation in regard to food tasting activities or snacks?

YESNO

If YES, please describe

The Child named above has my permission to participate in the designated Archaeology Camp. I understand that camp participation will involve some physical activity which could result in injury. I certify that my child is fully able to participate. I assume all risks to my child's participation and release NYCHAPS and its employees and volunteers from all liability, claim, expenses, and actions which may arise from injury or harm to the child as a result of camp participation.

In the event of medical emergency, I authorize NYCHAPS to designate a hospital, physician, or emergency personnel to provide care (including hospitalization, if necessary) to the child and release NYCHAPS from any liability for injury or harm which to the child which may result from this medical care. I understand that responsibility for payment of such medical care will be mine and certify that the child is covered by adequate medical coverage.

Please verify that you are human*

Parent or Guardian Signature

Date

NYCHAPS History Camp Medical Form