Critical Medical Information Form
This Bloomingdale Day Camp Critical Medical Information Medical Form is to be completed for ALL campers. One form per camper. This will provide us a quick summary of important medical information regarding your camper to include, allergies, medical conditions, medicine taken, Parental information and Emergency Information and Insurance Information.

If at any time anything changes or you wish to update this please contact Cyndy - Day Camp Registrar for assistance @ BDCregistrar@gmail.com

Camper's Full Name
Your answer
Campers Home Address
Your answer
Parent # 1
Your answer
Parent # 1 Cell Phone
Your answer
Parent # 1 Work Phone
Your answer
Parent # 2
Your answer
Parent # 2 Cell Phone
Your answer
Parent # 2 Work Phone
Your answer
Emergency Contact
Your answer
PHONE #
Your answer
EMERGENCY CONTACT
Your answer
PHONE #
Your answer
PRIMARY PHYSICIAN
Your answer
PHYSICIAN'S PHONE # AND ADDRESS
Your answer
INSURANCE (Name of company, ID #) NOTE: please provide copy of front and back of insurance card when submitting medical information/immunization copies
Your answer
LAST DATE OF TETANUS
MM
/
DD
/
YYYY
ALLERGIES - Please list ALL known Allergies in this area.
Your answer
ALLERGIES - HOW TO TREAT - Please list in detail exactly how the above allergy(ies) are treated. All treatments must be sent to camp in Ziplock bag clearly identified with Campers Name and detailed instructions.
Your answer
MEDICAL CONDITIONS - Please list any medical conditions that your Camper may have with any information that will help counselor understand more and how to help your Camper throughout the camp day.
Your answer
MEDICATIONS TAKEN - Please list any and all medications taken and what for. NOTE: If camper is going to need to take medications during the camp day medication MUST be in original container with clear directions for administering. Medication is to be placed in zip bag clearly labeled with campers name and detailed instructions and HANDED TO CAMP STAFF - DO NOT PLACE MEDICATIONS IN CAMPERS BACKPACK.
Your answer
OTHER INFORMATION YOU WOULD LIKE TO SHARE: Please list any other information not included above that will assist our staff to ensure that your camper has a great camp experience.
Your answer
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