Name: Lastname FirstName Age: Age Birth date: Birthdate Grade: Grade
Session Gender: Female
Custodial Parent #1 – ParentName1 Parent1Phone Parent1Address Custodial Parent #2/Emergency Contact – ParentName2 Parent2Phone Parent2Address Emergency Contact: EmergencyContact EmergencyContactRelation EmergencyContactPhone INSURANCE – Insurance? Carrier or Plan: InsuranceCarrier ALLERGIES Medication Allergy #1 : Medication Allergy #2 Medication Allergy #3 Food Allergy #1: Food Allergy #2: Food Allergy #3: Other Allergy: Other Allergy: Other Allergy: MEDICATIONS This Person takes no medication: NoMeds This Person takes medications: Meds Med #1: Med #2: Med #3: Med #4: Dosage: Dosage: Dosage: Dosage: Time of Day: Time of Day: Time of Day: Time of Day: Reason: Reason: Reason: Reason: Reaction: Reaction: Reaction Reaction: Reaction #2: Reaction: Reaction: Reaction: Reaction: Group # InsuranceGroup
RESTRICTIONS Dietary: Does not eat nuts: Other: 0 Explain Restrictions: GENERAL QUESTIONS Recent injury, illness or infections disease: Chronic or recurring illness/condition: Had Surgery: Frequent Headaches: Head Injury: Knocked Unconscious: No No No No No No Back Problems: Problems with Joints (knees, ankles) No No Describe:
Orthodontic Appliance being brought to camp : No Skin Problems (itching, rash, acne) Diabetes: Asthma: Mono in the past 12 months: Diarrhea/constipation: Sleep Walking: Abnormal Menstrual History: Bedwetting History: Eating Disorder: No No No No No No No No No
Weare Glasses, Contacts or Protective Eyewear: Yes Frequent Ear Infections: Passed out during or after exercise: Dizzy during or after Exercise: Seizure: Chest Pain during or after exercise: High Blood Pressure: Diagnosed with a heart murmur: Explain: No No No No No No No
Emotional Difficulties for which professional help was sought? No
This participant has had the following: Shots: TB Mantoux Test: Result of TB Test: DTP: 1/00 3/00 5/00 2/01 12/04