Stowe Running Camp 2021 Medical Info

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Please fill this out as thoroughly as possible as it will help us coordinate the camp!

Name of Camper

What is your insurance company?

What is your insurance policy number?

What is the date of your most recent physical?

YYYY

What is the name of your primary care physician?

If your child has a current or past physical injury or medical condition (including allergic reactions history) about which we should be aware, please note as such below and/or use the space below to detail and explain any such injury or condition for our athletic trainer. Please attach any records or other details about which we should be informed. Also, please note any medications that your child must have administered during the week. Medications must be provided directly to our athletic trainer along with explicit written instructions regarding dispensation:

Describe Specific Environmental, Food, and/or Medicine Allergies

Describe Asthmatic or related condition, if any:

Describe prescription Medications that your child takes. Please attach written instructions for our athletic trainer regarding dispensation.

Describe specific blood or organic diseases from which your child suffers:

Does your child wear glasses or contacts during athletic activities? Please describe:

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