Medical Information Form - Camp Herrlich Before And After School Programs
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2CAMP HERRLICH BEFORE AND AFTER SCHOOL PROGRAMS
MEDICAL INFORMATION FORM
Child’s Name (please print) __________________________________ Date of Birth _____________
Address______________________________________________ Home Phone________________
Parent/Guardian 1 Name ______________________ Parent/Guardian 2 Name _________________
Parent/Guardian 1 Work Phone _________________ Parent/Guardian 2 Work Phone ____________
Parent/Guardian 1 Cell Phone __________________ Parent/Guardian 2 Cell Phone_____________
Name of Child’s Physician _______________________________________ Phone ______________
Name of Child’s Dentist _________________________________________ Phone ______________
Medical Insurance Company _________________________________________________________
Insured Person ______________________________ Policy Number _________________________
Medical Insurance Company _________________________________________________________
Insured Person ______________________________ Policy Number _________________________
The following are names of people other than myself who can be contacted
IN CASE OF AN
,
/
if I cannot be reached. You must list someone
EMERGENCY
AND
OR MAY PICK UP MY ILL CHILD
besides yourself & your spouse.
Name
Relationship
Phone
In the event of an emergency I, _________________________________, authorize a Camp Herrlich
After School Staff Member to take my son or daughter to the hospital for treatment at my own
expense. I further give my consent that any emergency medical care needed may be given to my
son or daughter ____________________________________________ in case I cannot be reached.
Parent/Guardian Name (Please Print) __________________________________________________
Signature of Parent or Guardian ______________________________________ Date ___________
Revised 5/12
This is a two-sided document
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Parent category: Business