BROTHERS AND SISTERS EMERGING SUMMER CAMP Medical Form 2024

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MEDICAL FORM

Child's First Name *

Child's Last Name *

Date of Birth *

YYYY

Age *

Parent/Guardian Name *

Emergency Contact Name and Relation *

Phone *

Family Doctor's Name *

Family Doctor's Phone *

Family Doctor's Address *

Health Insurance Provider *

Group # (Optional: Only in case of emergency)

Does your health insurance have any special instructions in case of emergency that we should be aware of if you are not immediately available? *

Yes

If yes, explain:

CHILD’s HISTORY: Does your child currently have any of the following OR has your child ever been diagnosed with any of the following? *

*Asthma

*Concussion

Bleeding Tendencies

Rheumatic Disease

Spinal Disease

Knee Problems

Covid 19

Allergies

Bronchitis

Fractures

Pneumonia

Anemia

Bone Disease

None

Required

Does your child take any routine medications? *

Yes

Does your child have any physical handicaps? *

Yes

Any problems with vision or hearing? *

Yes

Any unusual shortness of breath? *

Yes

Any recent weight changes? *

Yes

I feel that my child is physically fit to participate in all camp activities. I shall not hold Brothers and Sisters Emerging it staff and partners responsible for any problems arising because of a previous health problem or injury. *

Yes

Parent or Guardian, please provide your electronic signature by typing your full name and today's date in the box below. By signing and submitting this form you agree to the statement above and attest that all information provided herein is accurate and correct. *

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