2009 Camper's Health Form
Type in your information in the form, print, sign, and mail with application form.
Last Name:
First Name:
Middle:
Social Security:
Date of Birth:
Address:
Name of Parent or Legal Guardian:
Home Phone:
Business (Mom):
Business (Dad):
Health History
Tetanus (date of last injection):
Surgeries (within the last year):
Broken Bones (within the last year):
Allergies:
Allergy to Drugs (if any):
Any medication child is on:
Any special health problems in the past:
Child's Physician:
Telephone # of Physician:
Do you have health insurance?
Yes
No
Name of parent's health insurance company:
Parent's health insurance number:
This is permission for treatment of my child by physicians and at the hospital for any medical or surgical emergency.
Legal Guardian __________________________________________ Date ___________