medical form

Camper’s Name ____________________________
Parent’s Name(s) ___________________________________________________
Phone # (daytime) _________________________ (Home) __________________
(Cell) ____________________________ (other) _____________________

Other emergency contact who will be available during this student is at camp: Name________________________ Relationship ______________Phone: ____________

Name of family physician: _________________________________ Phone:_____________
Name of family dentist/orthodontist__________________________ Phone:_____________

Please list any/ all allergies your child may have _______________________________
____________________________________________________________________
____________________________________________________________________
Note any other health concerns, if any _____________________________________
__________________________________________________________________
Date of last Tetanus shot ___________________________

List any medications needed while attending camp. Include written instructions please. (Dosage and times) __________________________________ ___________________________________
_______________________________________ ___________________________________ _______________________________________ ___________________________________

As parent or guardian of _______________________________ (camper’s name), in the event of sickness or accident, and in the event that I cannot be reached, I hereby give permission to Circle K camp, it’s Directors and employees, to give my child whatever emergency medical treatment is necessary, and /or to admit him or her to a hospital, or to place them under the care of a physician.

____________________________________ ________________
Signature of Parent or guardian Dates attending Camp
____________________________________
Signature of Parent or guardian

Please initial if the camp staff is able to administer to camper as needed:

Tylenol (Acetaminophen): ______ Advil (Ibuprophen): _____ Benadryl (Diphenhydramine)____

Insurance Policy Information
Policy Holder’s Name: __________________________________________________
Insurance Company Name: ______________________________________________
Policy #:_____________________________________________________________