St. Mary’s High School Summer Camp Health Form

St. Mary’s High School Summer Camp Health Form

2025
Important: This Health Form must be completed and signed by the parent/guardian before the first day of camp. This Form must include a signed copy of your camper’s most recent physical and medication orders by your family physician. See “File Upload” prompt below.
Camper’s Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Camper’s Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian’s Name*

First NameLast Name
Parent or Guardian’s Mobile Phone Number*
Please enter a valid phone number.
Parent or Guardian’s Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.

Height*
Weight*
BP
Pulse*
Respirations*
Please list any other pertinent medical concerns, appliances worn (glasses, contacts, etc.)

Physician's Name and Title

First NameLast Name
Physician’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician’s Phone Number
Please enter a valid phone number.
Camper’s Physical Form

(Forms must be valid within the last year (June 2024-June 2025 and signed by the physician).
Cancelof

Parent/Guardian Authorization
I hereby give permission for the person herein described to engage in all prescribed camp activities, except as noted by me and/or camper’s licensed medical physician. I hereby give permission for the Camp Director/Asst Camp Director/Camp RN to provide routine treatment to my child. In the event I cannot be reached in an emergency, I hereby give my permission for the camp to place my child in the care of a medical professional for medical services and treatment as deemed necessary with respect to my child’s health and safety.
Signature*

Clear
Please enter the Parent/Guardian Authorization Signature name below (if different from that which is shown)*

First NameLast Name
Date Signed

MonthDayYear
Date
Should be Empty:

Camper’s Health History