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Khalsa Camp Supplemental Medical Form
This form supplements the standard medical form we get from your child's physician. We still need that form along with an immunization record and proof of physical within a year of camp.
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Camper Name
Your answer
Camper Date of Birth
MM
/
DD
/
YYYY
Parent Name(s)
Your answer
Insurance Provider
Your answer
Insurance Plan #
Your answer
Medical Provider and Practice
Your answer
Medical Provider's phone #
Your answer
Dentist and Practice
Your answer
Dentist phone #
Your answer
Allergies
Your answer
Medications
Your answer
Pertinent Past Medical History
Your answer
Diet or Food Restrictions
Vegetarian
Vegan
Kosher
Halal
Gluten-free
None
Other:
Clear selection
Exercise level
low
1
2
3
4
5
high
Clear selection
Social History
yes
no
Seat Belts used routinely
Booster seat needed
Sunscreen used routinely
Bug repellant used routinely
Guns present in home
Second hand smoke exposure
yes
no
Seat Belts used routinely
Booster seat needed
Sunscreen used routinely
Bug repellant used routinely
Guns present in home
Second hand smoke exposure
Clear selection
School Information--what school does child attend and what grade will they have completed by summer
Your answer
School Information continued
yes
no
get's along well with others
responds to feedback/constructive criticism
follows multiple step directions
behavioral challenges
learning challenges
yes
no
get's along well with others
responds to feedback/constructive criticism
follows multiple step directions
behavioral challenges
learning challenges
Clear selection
Anything else you would like us to know or feel free to elaborate on any answer above if you want us to have more information.
Your answer
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