For Camp Use: Cabin Assigned ____ |
ã | DO NOT MAIL THIS FORM. BRING IT WITH YOU TO CAMP. | |
1. | Name ___________________________________________- (_____) ________________ |
2. | Name ___________________________________________- (_____) ________________ |
While Immunizations are not required for camp, |
RECOMMENDATIONS AND RESTRICTIONS WHILE IN CAMP
| |
Special Diet _____________________________________________________________________________________ | |
Special medicine (give name of medicine) _____________________________________ Is parent sending it? ______ | |
MEDICATIONS BROUGHT TO CAMP MUST BE IN ORIGINAL CONTAINER WITH INSTRUCTIONS ATTACHED. | |
Please note this includes vitamins and any over the counter medications. | |
Permission is given for my child to receive over the counter medication YES _____ NO ______ | |
Any specific activities that need to be restricted _______________________________________________________ | |
Swimming, diving, other?__________________________________________________________________________ | |
PARENTS AUTORIZATION
This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for my child as named above. Signature of parent or guardian__________________________________________Date_______________ |