Medical Examination Form Page 2

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Medical Examination Form Printable pdf

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2

Camper Name:

ESW Camps Medical Examination Form 2015 –2016 Page 2 of 2

THIS FORM IS TO BE BROUGHT TO CAMP ON REGISTRATION DAY.

DO NOT MAIL OR FAX TO THE MADISON OFFICE OR CAMP PRIOR TO ARRIVAL.

Additional health information: _____________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Any medically prescribed meal plans or dietary restrictions: _____________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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Use this space to provide any additional information about the participant’s behavior and physical, emotional, or

mental health about which camp staff should be made aware.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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I have examined the herein named individual and have reviewed the health history and find this person to be free of

any contagious disease. I find this individual able to participate in a camp experience with the previously listed

limitations.

____________________________________________________________________________________________

Signature of Licensed Medical Personnel

Date

____________________________________________________________________________________________

Printed Name

Title

____________________________________________________________________________________________

Address

____________________________________________________________________________________________

Phone

Fax

THIS FORM IS TO BE BROUGHT TO CAMP ON REGISTRATION DAY.

DO NOT MAIL OR FAX TO THE MADISON OFFICE OR CAMP PRIOR TO ARRIVAL.

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