Summer Camp Medical Form Page 2
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1
217. Do
y ou
h ave
t rouble
b reathing
o r
d o
y ou
c ough
d uring
o r
a fter
a ctivities?
r
r
If
y es,
e xplain:_____________________________________________________
18. Do
y ou
w ear
g lasses
o r
c ontacts
o r
p rotective
e ye
w ear?
r
r
If
y es,
e xplain:_____________________________________________________
19. Have
y ou
e ver
h ad
a ny
o ther
m edical
p roblem
( infectious
m ononucleosis,
d iabetes)?
r
r
If
y es,
e xplain:_____________________________________________________
20. Have
y ou
e ver
h ad
a
m edical
p roblem
s ince
y our
l ast
e valuation?
r
r
If
y es,
e xplain:_____________________________________________________
21. When
w as
y our
l ast
t etanus
s hot?
_ _________
I
h erby
s tate
t hat,
t o
t he
b est
o f
m y
k nowledge,
m y
a nswers
t o
t he
a bove
q uestions
a re
c orrect.
_________________________________
____________________________________
_________________
Signature
o f
A thlete
Signature
o f
P arent/Guardian
Date
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