Summer Camp Health Information Form Page 2
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2Physical Restrictions
No Yes Describe: ________________________________________________________
Diabetes
No Yes Describe: ________________________________________________________
History of Seizures
No Yes Describe: ________________________________________________________
Recent Surgeries
No Yes Describe: ________________________________________________________
Other Conditions
No Yes Describe: ________________________________________________________
Special Instructions related to allergies, bee stings, etc……
What is the child specifically allergic to?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________
Are you sending him or her with special medications/epi-pen/etc…? Yes
No
Describe: ____________________________________________________________________________________________
If yes, what do you want us to do in case of a related emergency?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________
Use this space to provide any additional information about the participant’s behavior and physical emotional or mental health
about which the camp should be aware.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________
Name of family Physician______________________________________________Phone:____________________________
Address: _____________________________________________________________________________________________
Name of family orthodontist/dentist______________________________________Phone:___________________________
Address: _____________________________________________________________________________________________
If your child will be participating in a full day of camp, if you wish the child to participate in the swimming pool sessions, please
indicate swimming ability/experience below.
Circle one: Inexperienced /Beginner
Moderately Experienced/ Novice
Experienced/Advanced -
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Emergency Information:
Contact # 1__________________________________________________________
Phone # 1 __________________________________________________________
Phone # 2 __________________________________________________________
Contact #2__________________________________________________________
Phone # 1 __________________________________________________________
Phone # 2 __________________________________________________________
Health Waiver/ Permission to Treat
Name: ____________________________________________________
As the legal parent and/or guardian of ___________________________, I grant permission to provide routine health care,
administer prescribed medications and seek emergency medical treatment to my child in case of emergency
In the case of doctor prescribed medication, I will provide a written letter with instructions to the Office Manager
Signed:
_____________________________________________________
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