|
MEDICAL FORM
NAME:____________________________________________________AGE:_______________________
BIRTHDATE:__________________________________________________________________________
ADDRESS:____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
EMAIL:_______________________________________________________________________________
PARENT'S
NAME:______________________________________________________________________
TELEPHONE HOME:___________________________WORK
:___________________________________
PARENT'S
NAME:______________________________________________________________________
TELEPHONE HOME:___________________________WORK
:___________________________________
IN CASE
OF AN EMERGENCY A THIRD PERSON TO CALL:______________________________________
____________________________________TELEPHONE:
_______________________________________
NAME OF
STUDENT'S DOCTOR:__________________________________________________________
TELEPHONE:_____________________24
HOURS:____________________________________________
IS YOUR SON OR DAUGHTER ALERGIC TO ANY MEDICINE?
YES______ NO______
SPECIFY_______________________________________________________________________________
____________________________________________________________________ BLOOD TYPE________
DATE OF LAST TETANUS SHOT OR BOOSTER:
____________________________________________
SPECIFY ANY OTHER ALLEGIES (FOOD, PLANTS, ANIMALS, ETC.)
_____________________________
______________________________________________________________________________________
IS YOUR
DAUGHTER OR SON TAKING ANY MEDICINES OR UNDER ANY MEDICAL CARE?
________
IF THE ANSWER IS YES, PLEASE GIVE ANY AND ALL MEDICINES THAT ARE CLEARLY
MARKED
WITH YOUR CHILD'S NAME, AND WRITTEN
INSTRUCTIONS TO THE ACOMPANING TEACHER BEFORE DEPARTURE FOR THE CAMP. ALL
MEDICINES MUST BE IN THEIR ORIGINAL PACKAGE.
COMMENTS
OR OTHER INFORMATION WE MAY NEED TO KNOW: _____________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
SIGNED: ________________________________
DATE:_________________________________
|