Medical Information Form Eureka College

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Medical Information Form
(Must be sent with Camp Application by May 31, 2016.)
Camper’s Name _____________________________________________________________
Male
Female
LAST
FIRST
MIDDLE
Date of Birth ______________________________________________________________ Age _____________
We would like to have the information requested below on file in the Summer Choral Camp Office.
PART I
Check all items that apply, past or present, to your health history. Explain any “Yes” answers.
ALLERGIES:
Food, medicines, insects, plants:
Yes
No
Explain: ___________________________________________________________________________________
GENERAL INFORMATION:
Yes
No
Yes
No
Asthma
Diabetes
Cancer/leukemia
Heart trouble
Convulsions/seizures
Hemophilia
High Blood Pressure
Kidney disease/stones
Explain:____________________________________________________________________________________
List any behavior disorders such as ADD or ADHD. This knowledge allows our staff to change teaching
approaches to better accommodate your child :_____________________________________________________
List any physical or behavioral conditions that may affect or limit full participation in outdoor physical games.
__________________________________________________________________________________________
List any medication to be taken at camp and what they are for. Include such drugs as antidepressants and Ritalin:
__________________________________________________________________________________________
__________________________________________________________________________________________

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