Age_____ Date of Birth_____________
Name of doctor__________________________
Phone number(_____)___________Health card #__________________________
Has your child received Tetanus immunizations? When?______________________________
Does your child have any known allergies?
If so specify____________________________________________________________
Does your child have any known reactions?__________________________
If so specify ____________________________________________________________
Does your child take any medication?_________________________________
If so specify_____________________________________________________________
Does your child have any known fears or problems? [e.g. bedwetting , fear of the dark or other .It is helpful for us to know in order to handle these tactfully] __________________________________________________________________________ __________________________________________________________________________
Any comments you wish to add?___________________________________________________________________________ ___________________________________________________________________________
In your absence, who do you wish to be contacted ? Please list 2 persons: name ,telephone, and relationship to the child. (1)________________________________________________________________________(2)________________________________________________________________________If necessary will you give permission to obtain medical assistance ? Yes____ No ____
Signed (Parent or Guardian ) _______________________________ ??In my opinion, the above named camper is physically fit for camp activities. Please list any exceptions __________________________________________________________________________ Signed __________________________________ Date ________________________ * Any medication a staff member or camper brings to camp must be handed over to the camp director with instructions written clearly. Please mail or bring this form to camp with your child. Please inform us, prior to registration, if there are any serious health or psychological concerns that may affect a child’s stay at camp.A phone call would be appreciated.