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| HEALTH FORM |
HEALTH FORM |
| Fitch Mountain Day Camp "HEALDSBURG'S ORIGINAL DAY CAMP" |
Medical Form can be printed from this web page. Please move courser to the right and print
FITCH MOUNTAIN DAY CAMP PROGRAM HEALTH FORM
TODAY’S DATE:____________________________________________________________
NAME OF CHILD:___________________________________AGE ____________________
DATE OF BIRTH:____________________________________________________________
HOME ADDRESS:___________________________________________________________
HOME PHONE:_____________________________________________________________
GRADE/SCHOOL YEAR:______________________________________________________
SCHOOL’S NAME___________________________________________________________
PARENTAL PERMISSION:
My child has my permission to participate in the Fitch Mountain Day Camp Program’s activities including summer swimming. My child’s
swimming ability is: (circle one) BEGINNING INTERMEDIATE ADVANCED
In the event of the need for emergency, medical treatment for my child, I give my permission to the Day Camp Staff to obtain necessary,
emergency, medical treatment. We, the undersigned parent or guardian of (PRINT NAME OF CHILD)_______________________, a minor,
do hereby consent to any x-ray exam, anesthetic, medical or surgical diagnosis
or treatment and hospital service that may be rendered to said minor under general or specific instructions of any physician or at a licensed
hospital. It is further understood that this consent is given to authorize the physician to exercise their best judgment as to the requirements
of such treatment.
HOME ADDRESS:______________________________________________________________________________
PHONE’S: HOME:_________________________WORK:_________________________CELL:_________________
PRINT MOTHER’S NAME:________________________________________________________________________
MOTHER’S___________________________________________________________________________________
SIGNITURE___________________________________________________________________________________
PRINT FATHER’S NAME_________________________________________________________________________
FATHER’S SIGNITURE__________________________________________________________________________
HOME ADDRESS:______________________________________________________________________________
PHONE #’S: HOME:__________________________WORK:_________________________CELL:_______________
LEGAL GUARDIAN’S NAME:____________________________________SIGNATURE:________________________
HOME ADDRESS:______________________________________________________________________________
PHONE #’S: HOME:_________________________WORK:__________________________CELL:_______________
*IF UNABLE TO CONTACT MOTHER, FATHER, OR GUARDIAN, PLEASE CONTACT:
________________________RELATIONSHIP:___________________________PHONE #____________________
HEALTH HISTORY:_____________________________________________________________________________
GENERAL HEALTH :____________________________________________________________________________
ALLERGIES:__________________________________________________________________________________
LEARNING DIFFICULTIES:_______________________________________________________________________
DIETARY NEEDS:______________________________________________________________________________
OTHER “SPECIAL NEEDS”_______________________________________________________________________
IS YOUR CHILD TAKING MEDICATION ON A REGULAR BASIS?___________________________________________
IF SO, PLEASE DESCRIBE:_______________________________________________________________________
DATE OF LAST TETANUS BOOSTER:_______________________________________________________________
NAME OF FAMILY PHYSICIAN:_____________________________________________________________________
PHONE #:____________________________________________________________________________________
MEDICAL INSURANCE COMPANY:_________________________________________________________________
POLICY #:____________________________________________________________________________________
IF WE CANNOT REACH YOU, WHO IS AUTHORIZED FOR US TO CALL TO PICK-UP YOUR CHILD:
1._________________________________________________________ NUMBER
#:_________________________________________________________ PHONE
2._________________________________________________________ NUMBER
#:_________________________________________________________ PHONE
3._________________________________________________________ NUMBER
#:_________________________________________________________ PHONE
REVISED: 5/08 SSH
"Day Camp....not just a place for children to go... but a place for children to grow" |