Universal Health Form For Camp printable pdf download

Universal Health Form For Camp

Melody Pines Day Camp, Inc.

UNIVERSAL HEALTH FORM FOR CAMP

Name:________________________________________________________

D.O.B.:______________________ Date of Exam: ____________________

WT: ________________ HT: ________________ BP: _________________

VISION: ____________________ HEARING: _______________________

IMMUNIZATIONS:

Date of Last Tetanus:

_________________

Date of Repeat MMR

_________________

Date of Hepatitis

_________________

PHYSICAL EXAM:

Normal: Y or N (please circle)

Exceptions/Abnormalities: _______________________________________

_____________________________________________________________

Cleared for participation: Y or N (please circle)

(Swimming, boating, sports, all camp activities)

Exceptions to participation: Y or N (please circle)

(Note exception(s) below)

_____________________________________________________________

Medications: __________________________________________________

Allergies: _____________________________________________________

PHYSICIAN’S SIGNATURE: ____________________________________

DATE: __________________

Universal Health Form For Camp