Camper Health History Form

St. John's Parish Day School

Camper Health History Form
Camper's Full Name*
Email*
example@example.com
Current Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
First Emergency Contact (Parent or Legal Guardian) Full Name*
First Emergency Contact Phone Number*
Second Emergency Contact Full Name*
Second Emergency Contact Phone Number*
Physician Full Name*
Physician Phone Number*
Are there any health problems—including physical, psychiatric, and behavioral problems—of which we need to be aware?*

YesNo
Please explain any health problems*
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?*

YesNo
Please explain any needs*
Immunization Information
My Camper resides...*

within the United States, a U.S. territory, or the District of Columbia.outside the United States, a U.S. territory, or the District of Columbia.
State/territory/district in which the Camper resides

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is the Camper exempt from any immunizations?

YesNo
Please list any exempted immunizations*
Country in which the Camper resides

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
You will need to provide the School with a Health Department form DHMH-896 (Record of Vaccination or Immunity) completed by a medical provider before your Camper's registration can be completed.

Forms are available here: Maryland Department of Health DHMH-896
By checking the box below, you acknowledge that your Camper's registration will not be complete until a complete form DHMH-896 has been received.

I understand
Signing Parent/Guardian Full Name*
Date Signed*

MonthDayYear
Date
Parent/Guardian Signature*
Electronic Signature Agreement*

By checking this box, you acknowledge and agree that your electronic signature on this form is the legal equivalent of your manual signature.
Information collected by this form satisfies the requirements of Maryland Department of Health and Mental Hygiene (DHMH) Form 4768, current version published January, 2015.
Should be Empty:

St. John's Parish Day School