Medical Form

Once you complete this form please fill out the School Authorization form.


CAMP SUMMERSET – MEDICAL AND TRANSPORTATION FORM
Please be advised that all information on this form will be kept confidential. Answer all the questions, sign, and return with your application.
Name:
Date of Birth:

Address:

Phone Number:
E-mail:

Is your child allergic to ANY foods or medicine?:

Is your child allergic to BEE STINGS?:

Does your child take any medication?:
(If yes, please provide details)
 

Any physical activity he/she cannot participate in?:

Any other important health related information?:

Persons AUTHORIZED to pick up my child
NAME/PHONE
RELATIONSHIP TO CHILD

1.

2.

3.

Name & Phone # of Doctor:

In case of emergency, we can be reached at the following phone numbers: Please number the order in which to call

Home:
Work:
Cell:

If I CANNOT be reached, call:

Or call:

Parents or Guardian Authorization: In case of emergency, if family physician CANNOT be reached, I hereby authorize my child to be treated by "CERTIFIED EMERGENCY PERSONNEL" (i.e. EMT, first responder, ER Physician):
YesNo

Parent Signature:
Date: