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 2010 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):
Parent Email Address:
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 ___________