Summer Camp Health Form - English - Hands of Hope America

Layout

Child's Name *

Age *

Gender *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

In Case of Emergency

Layout

NAME *

First

Last

Relationship *

Cell Phone *

Work Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

General Medical History

Is the Child up-to-date on all immunizations? *

Layout (copy)

Covid Vaccination? *

Has your child tested POSITIVE for COVID in the last 2 weeks? *

Date(s) of Vaccination *

If Yes, do they still have symptoms?

If NO, has the child had a NEGATIVE test in the last 3 days?

Does your child have any food, medication or environmental allergies? *

Allergies? Check all that apply:

Food
Medication
Environmental

Please list and explain any allergies:

Significant Medical History (surgery, injuries, serious illness):

List any Medical Problems (asthma, seizures, headaches):

Is any medication required? *

List any medications taken regularly:

In an emergency does this child require additional assistance (more than other children of the same age or in the same group) to evacuate? *

Please Describe:

In the event that the Summer Camp must be evacuated, are there medications or supplies that must be taken with this child? *

I consent to the following administration: sunscreen - topical product or lotion, exact dosage: liberal application per exposed area, to be administered: before high sun exposure. *

Parent's Email *

Print Parent/Guardian Name *

Parent/Guardian Signature *

Today's Date *

R.I.S.E. SUMMER CAMP HEALTH FORM

R.I.S.E. SUMMER CAMP
HEALTH FORM