Physical Form - Camp Como

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The COLORADO DEPARTMENT OF HUMAN SERVICES DIVISION OF CHILD
CARE mandates that the camper’s parent/guardian provide a health history
to Camp Como as well as a statement confirming a physical examination
has been performed within the preceding 24 months by a licensed
physician or a qualified, licensed nurse practitioner demonstrating that the
camper is capable of attending camp. Current written authorization from
the medical provider for any required prescription or non-prescriptive
Physical Form
medicines is mandatory.
Camper Name:
Due 2 weeks before camp
Dates Attending Camp:
P.O. Box 36, Como, CO 80432
Email
Church Registered With:
Fax
719-836-0461
TO BE COMPLETED BY A PHYSICIAN/CNP
Medical conditions Camp Como should be aware of: _________________________________________________________________
___________________________________________________________________________________________________________
__________________________________________________________________________________________________________
List any serious illnesses or operations and dates: __________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Special instructions (e.g. dietary restrictions, exempted activities, etc.) ________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Allergies (i.e. drugs, food, other): _______________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________ was given a physical examination on _______/_______/_______.
(Must be within 24 months of designated camp.) S/he is capable of active participation in a regular camp program except as noted
above.
Signature of
Physician/CNP_______________________________________________
_____________________
Date
Printed Name_______________________________________________Address__________________________________________
Phone (_______)____________________________City______________________________State___________Zip______________
Rev. 1/16

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