Camper Health History Form
Ensure all information is completed. Email getmoovinggames@gmail.com with any questions.
Camper Name
*
First Name
Last Name
Camper Birthdate
*
-
Month
-
Day
Year
Date
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact (Parent or Legal Guardian)
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact #2
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Physician or other provider of medical care
*
Primary Care/Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are any health concerns (physical, psychiatric, or behavioral) of which we need to be aware? If yes, please explain.
*
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? (Please note: Get Mooving Games staff will not administer medication to campers). If yes, please explain.
*
Immunizations
For campers who reside outside the United States , a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896. Email getmoovinggames.com to acquire the form
Does the camper have any immunization exemptions because of a parental/guardian objection or medication contraindication? If yes, please list.
*
Parent/Legal Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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Should be Empty: