Medical Application
For Child's Doctor to Complete.

Questions can be directed to apply@clarksvillecamprainbow.org or Jereme Miner, Camp Director: 931-320-3473.
Child's Last Name:
Child's First Name:
Child's Date of Birth:
MM
/
DD
/
YYYY
Weight:
Height:
Physician's Information:
Physician's Name:
Practice Name:
Street:
City:
State:
Zip Code:
Office Phone:
Office fax:
After Hours Contact Numbers:
Date of child's last exam or office visit:
Child's diagnosis and original date of diagnosis (please indicate if in remission):
** With this application, children with Cystic Fibrosis must provide sputum culture proof of no multiple drug resistant pseudomonas**
Culture Done:
N/A:
Other diagnosis, not related to primary diagnosis:
Other helpful information:
What other medical treatments or procedures will the Camp Rainbow Nursing Staff need to provide the week of camp besides medications?
(Examples; urinary cauterization, breathing treatments, Chest percussion, G Tube feedings, wound dressing changes)
Medications given to the child at home:
Medication Name, Amount Give, and How Often
Medications the child should take while at Camp during the week of June 8-13, 2020
Allergies
Any known allergies to medications (Please List):
Is the child allergic to any medications? If Yes, please list:
Any Latex allergies?
Has the child had Chicken Pox?
Any treatments or surgeries prior to Camp?
Any diet restrictions while at Camp?
Any lab work required while the child is at Camp?
Immunization Record
Please complete this section below.
DTaP/Hep B/IPV (# and Date:)
Hepatitis B (# and Date:)
DtaP/DT/Td (# and Date:)
DtaP/Hib (# and Date:)
Td Booster (# and Date:)
Hib (# and Date:)
Hib/Hep B Tdap (# and Date:)
Polio (# and Date:)
Pneum Conj (PCV) (# and Date:)
MMR (# and Date:)
Varicella (# and Date:)
Hepatitis A (# and Date:)
Meningococcal (# and Date:)
The information status on the above named child is accurate according to the best available information on file.
By agreeing to the terms and conditions you are confirming the above information is accurate and current to the best of your knowledge.
Do you agree to these terms and conditions?
Physician's Signature:
Please type your name:
Date:
MM
/
DD
/
YYYY
Submit
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