Summer Camp Medical Form

MEDICAL INFORMATION

Name ____________________________________________________________________

Address _________________________________________________________________

Age_____    Date of Birth_____________

Name of doctor__________________________

Phone number(_____)___________Health card #__________________________

Other Medicare_______________________

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.

Children's Residential Riding Camp and School