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MEDICAL INFORMATION 2024
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* Indicates required question
Email
*
Your email
Name:
*
Your answer
DOB
*
MM
/
DD
/
YYYY
Medical & Health Care Information:
Dr.'s Name and Phone
*
Your answer
Health Card:
*
Your answer
Participants Diagnosis & other Assessment
*
Your answer
Legal Parent/Guardian Information (
Name, Address, Postal Code, Cell-Work-Home Phone)
*
Your answer
Emergency Contact:
(
Name, Address, Postal Code, Cell-Work-Home Phone)
*
Your answer
Secondary Emergency Contact
(
Name, Address, Postal Code, Cell-Work-Home Phone)
*
Your answer
Immunization:
Date of last Immunization/Booster
MM
/
DD
/
YYYY
TDP:
Tetanus-Diphtheria-Polio
MM
/
DD
/
YYYY
MMR:
Measles-Mumps-Rubella
MM
/
DD
/
YYYY
Chickenpox:
MM
/
DD
/
YYYY
Hepatitis B
MM
/
DD
/
YYYY
HIB:
Hemophilus-Influenza Type B
MM
/
DD
/
YYYY
COVID
MM
/
DD
/
YYYY
Health Information:
*
Appendicitis
Asthma
Bladder Control
Bowel Control
Chickenpox
Clotting Disorder
Corrective Eyewear
Dental Appliances
Diabetis
Ear Infections
Eating disorder
Epilepsy
Frequent Colds/Sinus Trouble
Frequent Earaches/Infection
Frequent Hearing Difficulties
Headaches
Hearing Aid
Heart Condition
Hepatitis
Home Sickness
Hypertension
Kidney Disease
Measles
Mumps
Seizure Disorder
Severe Stomach Aches
Skin Condition
Sun Sensitivity
Tonsilitis
Urinary Tract Infection
Vision Difficulties
Whooping Cough
Required
Additional History/Information
*
Your answer
Recent Illness, Operations or Injuries
*
Your answer
Is the participant under any form of treatment/medication for any illness, condition or injury, other than treatment of their neurological disorder?
If YES, please explain
*
Your answer
Will this condition limit or affect participation in activities? If YES please explain
*
Your answer
Additional Information:
*
Your answer
Allergy Information:
Medication-
Drug Name-Reaction-Anaphylactic?
*
Your answer
Food
:
Food Name-Reaction-Anaphylactic?
*
Your answer
Insect Stings/Bites
Insect Name, Reaction-Anaphylactic?
*
Your answer
Seasonal/Environmental:
Name-
Reaction-Anaphylactic?
*
Your answer
Medication being sent: All medication must be in clearly labelled original packages from a pharmacist. Medication Administration Sheet has to be filled out for each medication and handed to checking in staff.
Over-the-counter medication in original container( After Bite, Tylenol, Anti Histamine)
*
No Medication
Yes-prescription medication administration Sheet(s) included
Yes-over-the-counter medication administration Sheet(s) included
Required
Does the participant take any other medication that will not be sent to Camp
Please provide information in case of an emergency
*
Your answer
Additional Information
*
Your answer
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