Honey Creek Summer Camp Health Form
Name:________________________________________________________________
Last First Middle
Age:________
Birthdate: ____/____/____ Sex:________
Address:________________________________ ______________ _______________
Street City Zip
Phone: (______) __________________ (______) ________________________
Home Work
IN CASE OF EMERGENCY,
NOTIFY:_____________________________________
Name Relationship
Address and phone if different from
above:_____________________________________
_______________________________________________________________________
Are all immunizations up to date? Yes___ No___
If no, list which
ones:_______________________________________________________
List all real allergies: (penicillin,
etc.)____________________________________________
________________________________________________________________________
List any illnesses/injuries of recent history (give
dates):_____________________________
ญญญญญญญญญญญญญญญ________________________________________________________________________
Is the above named person on daily medication? Yes ___ No ___
If yes, give medications and dosages below:
________________________________________________________________________
________________________________________________________________________
In case
of need, I authorize required medical care
for my child by the camp nurse, physician, or by any hospital or physician
rendering medical service. I also authorize any hospital or physician to
release any medical or insurance information to the camp representative if the need arises The hospital or physician is
released from all legal responsibility or liability that may arise from the
release of this medical information.
Parent/Guardian
Signature:_______________________________ Date:_________
I give
permission for my minor child, whose name appears to the right, to participate
in ropes course activities at the Georgia Episcopal Camp and
Parent/Guardian
Signature:_______________________________ Date:_________