DISCOVERY- SUMMER 2012 MEDICAL FORM
ENROLLMENT
INFORMATION:
| Student's Name: | |
| Date of Birth: | |
| Grade Entering Sept. 2012: | |
| Name of School: | |
| Parent's Name: | |
| Home Address: | |
| Home Phone: | |
| Work Phone: | |
| Cell Phone: | |
| Physician Name: | |
| Physician Phone: |
EMERGENCY CONTACTS:
| NAME: | HOME: |
| CELL: | |
| NAME: | HOME: |
| CELL: |
MEDICAL QUESTIONAIRRE MUST BE COMPLETED BY PARENT:
1. Does your child any allergies or dietary
restrictions? Yes or No If yes, please specify:
__________________________________________________________________________
2.
Does your child require medication on a daily basis? Yes or No If yes, please
specify:
__________________________________________________________________________
**DOCTOR'S PRESCRIPTION REQUIRED TO ADMINISTER MEDICATION TO CAMP NURSE**
3. Does your child have any medical/health concerns? Yes or No - If yes, please specify:
4. Is your child restricted from any physical activity? Yes or No
If yes, please specify:
__________________________________________________________________________
5.
Has your child had any serious illness, injury, or operation? Yes or No
If
yes, please specify:
__________________________________________________________________________