Prime Time Camp Medical Form 2025

MEDICAL FORMS & WAIVERS
This form is to be completed for each child, as it becomes a part of the child’s record. Parents can fill it out; a doctor’s signature is not needed. Please complete all the information and return to the camp as soon as possible, but NO LATER than the first day of camp. (ANY CHILD WITHOUT HEALTHFORMS WILL NOT BE PERMITTED INTO CAMP ON THE FIRST DAY).
Name*

First NameLast Name
Grade*
Date of Birth*
Allergies*
Mothers Name*

First NameLast Name
Fathers Name*

First NameLast Name
Home Phone*
Please enter a valid phone number.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Work Phone*
Please enter a valid phone number.
Cellular*
Please enter a valid phone number.
Mother's Work Phone*
Please enter a valid phone number.
Cellular*
Please enter a valid phone number.
Local Doctor's Name*
Phone*
Please enter a valid phone number.
EMERGENCY MEDICAL INFORMATION
My child(Ren) has or is subject to (check or give detail below).
Select one or multiple

AsthmaConvulsionsHeart TroubleDiabetesFaintingHigh Blood PressureAllergiesContact LensesOther
If your child has ANY medical problems, please list along with instructions for the counselor and/or nurse.
Any sport(s) your child is not allowed to participate in? Please explain:
MEDICAL HISTORY
Date of most recent physical exam (month and year)*
Does your child have any current health problems?*

YesNo
Is your child now under medical care or taking medicines?*

YesNo
Has there been any surgery, injury, illness, allergy, or changes in health status since last physical exam?*

YesNo
Please Explain
Tylenol is available for headaches or other pain without fever. If you wish your child to have Tylenol in these cases, please indicate the dosage below and sign your initials.
Number of Tablets Adults (325 mg)
Initials of Parent
or
Number of Tablets Junior/Chewable (160 mg)
Initials of Parent
or
Children’s Tylenol (Liquid) - 5mL = 1 teaspoon (160 mg)
Initials of Parent
In case of emergency notify local contacts. Please list three additional local numbers (including cellular) of people (NOT including parents) who will be available in an emergency to pick up a sick child or seek medical advice in the event a parent cannot be reached.
1. Name*
Relationship*
Phone*
Cell*
2. Name*
Relationship*
Phone*
Cell*
3. Name*
Relationship*
Phone*
Cell*
Please list siblings/grade*
Upload Immunization Record*

Cancelof
To the best of my knowledge, the medical history is correct and accurate. I see no reason to restrict activity and give my permission for participation in all activities and trips except as specifically noted above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order an injection, anesthesia, or surgery for my child as named above.
Parent Signature*

Clear
Date*

MonthDayYear
Date
By signing this agreement, I hereby give permission for my child(ren) to participate in all camp activities and be photographed during activities with the understanding that such photographs may be used for promotional and advertising purposes. In case of an emergency, the Prime Time Day Camp staff will make every effort to contact me or any person whom I designate. In the event nobody could be reached I authorize Prime Time Day Camp staff to provide medical assistance for my child.
I agree*

YesNo
By signing this agreement, I hereby expressly consent to receive communications from or on behalf of Prime Time Day Camp via, for example, and not limited to, telephone, mobile phone, text messaging, email, mail or any other medium as it may become available. I further expressly consent to receive autodialed and pre-recorded telemarketing calls from or on behalf of Prime Time Day Camp at the telephone number provided in this contract, and any that I may subsequently provide, including my mobile phone number, if applicable. I understand that consent is not a condition of purchase. This provision shall survive the termination of this contract.
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
I hereby waive, release and discharge any and all claims for damages, personal injury and property damages which may occur to my child as a result of participation in Prime Time Day Camp. This release is intended to discharge in advance Dr. David Matalon, Robert “Bobby” Matalon and all Prime Time Day Camp Staff from any and all liability, even though that liability may arise out of perceived negligence on the part of the parties mentioned above
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL FORMS & WAIVERS

EMERGENCY MEDICAL INFORMATION

MEDICAL HISTORY