Health History And Emergency Form - Wheaton Park District

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Wheaton Park District
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2016 Health History and Emergency Form
Name of Camp:____________________________________________________
Session:________________________
Name_____________________________________________ Birthday_________ Age______ Grade in Fall__________
Home Address_______________________________________ City_______________________ Zip Code____________
Parent/Legal Guardian__________________________________________ Phone Number________________________
Address_____________________________________________ City______________________ Zip Code____________
(If different from address above)
Work Phone:________________________________________ Cell Phone:____________________________________
Second Parent/Legal Guardian_____________________________________ Phone Number_______________________
Address_____________________________________________ City______________________ Zip Code____________
(If different from address above)
Work Phone:________________________________________ Cell Phone:_____________________________________
If not available in an emergency, notify:
Name_________________________________________ Relationship_________________________________________
Cell:_________________________________________ Home Number:________________________________________
Address_____________________________________________ City______________________ Zip Code_____________
Insurance Information
Is the participant covered by family medical/hospital insurance? ___yes
___no
If yes, indicate carrier or plan name_______________________________________________ Group #______________
Carrier Address_______________________________________ City____________________ Zip Code______________
Name of Insured______________________________________ Relationship to participant________________________
Physician Information
Name of Physician__________________________________________________ Telephone_______________________
Address_____________________________________________ City____________________ Zip Code______________
Name of Dentist____________________________________________ Telephone_______________________________
Address_____________________________________________ City____________________ Zip Code_______________
Authorization for Emergency Medical Treatment
I authorize the Wheaton Park District to take action as necessary in case of an emergency.
__________________________________
__________________________________________________________
Date
Signature of Parent or Guardian
Please see back side of form for health information

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