KAVI YO! Summer Camp Medical Information
Name *
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Email *
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Policy Number *
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Name of Health Insurance Provider
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Primary Physician
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Address
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Phone
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Please list any media problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures)
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Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
If Yes, explain (if no, write n/a) *
Your answer
Is your child allergic to any type of food or medication? *
If Yes, explain (if no, write n/a) *
Your answer
Does your child require a special diet?
If Yes, explain (if no, write n/a) *
Your answer
In case of emergency contact:
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I understand that I will be notified in the case of a medical emergency involving my child. In the event I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. *
Required
I understand that the KAVI Young Ones Summer Innovation Camp or KAVI will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. *
Required
Dietary restrictions *
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