TYC 2019 Health Information Form
This form provides detailed information about health, insurance, medications, and emergency contacts to be used at TYC 2019 by our nurse to provide medical care as needed. For the safety of all participants, any prescription medications (except inhalers and EpiPens) must be locked in the nurse's medical cabinet for the week. The participant will be responsible for taking their own medications at the appropriate times, as dispensed by the nurse. Please refrain from supplying your own over-the-counter medications; these will be provided by the camp RN. This form also gives permission from the parent/guardian of students under the age of 18 to receive medical treatment in the case of an emergency.
Email address *
Participant Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Complete Address *
Your answer
Parent/Guardian Name (for those under 18)
Your answer
Relationship (of above named parent/guardian)
Your answer
Parent/Guardian Phone (Home)
Your answer
Parent/Guardian Phone (Cell)
Your answer
Parent/Guardian Phone (Work)
Your answer
Secondary Emergency Contact Name *
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Phone (Home) *
Your answer
Emergency Contact Phone (Cell) *
Your answer
Emergency Contact Phone (Work)
Your answer
Primary Care Physician (Name and/or Practice) *
Your answer
PCP Phone Number *
Your answer
PCP Address *
Your answer
Dentist Name *
Your answer
Dentist Phone Number *
Your answer
Dentist Address *
Your answer
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