Address, City, State Zip (address of student and parent/guardian 1) *
Your answer
Parent/Guardian 2 - Name
Your answer
Parent/Guardian 2 - Email
Your answer
Parent/Guardian 2 - Phone
Your answer
Medical Information
Medical Insurance Carrier
Your answer
Policy or Group #
Your answer
Carrier Address
Your answer
Family Physician - Name
Your answer
Family Physician - Phone
Your answer
Dentist/Orthodontist - Name
Your answer
Dentist/Orthodontist - Phone
Your answer
Health History
Check all that apply & provide explanation/dates (below)
Provide dates/explaination of any items checked above
Your answer
Chronic or Recurring Illness/Medical Condition
Your answer
Dietary Restrictions
Your answer
Blood Type (if known)
Clear selection
All immunizations (MMR, Tetanus, Hepatitis) current?
Clear selection
Describe student's swimming ability?
Clear selection
Medication
Please bring student's medication that is needed to check-in. Leaders will distribute medicine based on dosages and time. We will bring a medical first aid kit with basic medication.
Medication 1 - Name
Your answer
Medication 1 - Dosage
Your answer
Medication 1 - Reason for taking
Your answer
Medication 2 - Name
Your answer
Medication 2 - Dosage
Your answer
Medication 2 - Reason for taking
Your answer
Medication 3 - Name
Your answer
Medication 3 - Dosage
Your answer
Medication 3 - Reason for taking
Your answer
Is there any other information you feel the leaders should know in advance about your student?
Your answer
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