AASTC 2017 Medical Form
Please fill this form out to the best of your knowledge.
All fields require a response.
If a question does not apply to your camper, please type N/A.

If you have more than one camper, please fill this fill this out separately for each camper and submit.

GENERAL INFORMATION
LAST Name
Your answer
FIRST Name
Your answer
Goes By
Your answer
Gender
Date of Birth
MM
/
DD
/
YYYY
PARENT/GUARDIAN INFORMATION
Please make sure this is accurate, this is your camper's emergency contact information.
1st Parent/Guardian Name
Your answer
Home Phone Number
Your answer
Best time to be reached
Your answer
Work Phone Number
Your answer
Best time to be reached
Your answer
Cell Phone Number
Your answer
Best time to be reached
Your answer
Home Address
Your answer
City
Your answer
State
Your answer
Zipcode
Your answer
2nd Parent/Guardian Name
Your answer
Home Phone Number
Your answer
Best time to be reached
Your answer
Work Phone Number
Your answer
Best time to be reached
Your answer
Cell Phone Number
Your answer
Best time to be reached
Your answer
Home Address
Your answer
City
Your answer
State
Your answer
Zipcode
Your answer
MEDICAL CARE INFORMATION
Family Physician (Name and Office)
Your answer
Phone Number
Your answer
Dentist/Orthodontist
Your answer
Phone Number
Your answer
Medical Insurance Carrier
Your answer
Carrier Address
Your answer
Policy/Group#
Your answer
Phone Number
Your answer
HEALTH HISTORY
Chronic or recurring illness or medical condition:
Your answer
The applicant is under the care of a physician for the follow condition(s):
Your answer
Explanation of any reported loss of consciousness, convulsion, or concussion:
Your answer
For Female Camper: Has this person menstruated?
If no, has she been told about it?
Special consideration:
Your answer
Any treatment to be continued at camp?
If yes, please explain:
Your answer
Any medication to be administered at camp?
If yes, please specify medication(s) and dosage instruction(s):
Your answer
Any medically prescribed meal plan or dietary restrictions?
If yes, please specify details:
Your answer
Any allergies (food, drugs, plants, insects, etc.)?
If yes, please explain:
Your answer
Activities to be encouraged or limited?
If yes, please explain:
Your answer
Current Weight
Your answer
Check all health conditions that apply:
Required
Please list all prescription drugs:
Your answer
OVER-THE-COUNTER MEDICATIONS
*NOTE: We have a supply of Children's Zyrtec, Ibuprofen, and Tylenol. Parents must provide pediatrician-recommended medications for campers under 12 if you know your camper will require then at camp.
Check all that we can administer (If sickness occurs at camp):
Required
PARENT/GUARDIAN CONSENT
Please read:

I am the parent/guardian of the above named child, and give consent for my child to attend the All-Arts, Sciences, & Technology Camp. I understand that my child's participation will include some physical activity. I acknowledge that injuries may occur as a result in the participation in this camp, and I accept that consequence. I have advised our family physician that my child wishes to participate in the AASTC, and our physician has approved of this participation. I authorize camp personnel to act according to their training and best judgement to provide medical care. I give permission for a physician or hospital emergency room to administer the necessary care if injured or in need of medical attention. I give permission to camp staff health professionals to view and maintain my camper's medical records during camp and to share them with medical personnel in the case of an emergency. I understand and agree that I am responsible for any charges for medical treatment.*

By checking "I agree" and entering your first and last name and the date, you are effectively providing your signature, indicating that you agree to the terms above* and the form is to the best of your knowledge true and accurate.
Required
Parent/Guardian Name
Your answer
Today's Date
MM
/
DD
/
YYYY
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