TOWN OF BLOOMING GROVE SUMMER CAMP PROGRAM 2008

MEDICAL HISTORY FORM

Camper’s Name ______________________________ Phone (H)______________ (B)_____________

Address____________________________________________________________________________

(Including name of road/street, P.O. Box #)

Age_________ Date of Birth___________________ School______________________ Grade_______

Are you a resident of the Town of Blooming Grove?             Yes_________ No_________

(A resident pays property taxes to, and votes in Blooming Grove)

Emergency Name and Phone (not your own)    1.__________________________________________

Please List two Names                                                    2.__________________________________________

MEDICAL HISTORY

Has your child been under any medical care within the past year?    Yes______ No______

Reason:___________________________________________________________________________

Is the child on any medication now?      Yes______ No______

What? ____________________________________________________________________________

(Written Doctor approval is needed before the Camp Medical Personnel can administer medication)

Is your child allergic to Penicillin, or any other drug?  Yes______ No______

What? ____________________________________________________________________________

Does your child have other allergies? (i.e. bee stings, nuts, grass, etc.)            Yes______ No______

What? ____________________________________________________________________________

Is your child subject to:

___ Fainting Spells                               ___ Hay Fever                            ___ Headaches

___ Eczema                                         ___ Tonsillitis                            ___ Wetting

___ Stomach Upsets                             ___ Diabetes                              ___ Asthma

___ Abdominal Pains                           ___ Cramps (Where?_______)      ___ Convulsions

___ Frequent Sore Throats                    ___ Ear Infections                      ___ Sinus Trouble

___ Serious Ivy/Oak/Sumac Poisoning   ___ Bronchitis                            ___ Constipation

___ Other _____________________

Does your child have:        ___Lung Problems  ___Kidney Problems  ___Heart Problems

          ___Hernia  ___Epilepsy  ___Other_________________________________________________

Does your child have emotional, or mental limitations?                   Yes______ No______

If yes, please elaborate: ______________________________________________________________

Has your child been exposed to any contagious disease in the past 3 weeks?        Yes____ No____

If yes, what and when? ______________________________________________________________

Should your child be restricted from any activity?     Yes___ No___ If so, what? _________________

IMMUNIZATION RECORD (Please indicate dates) Camper must have tetanus shot.

***Optional~ Copy of medical records OR this section filled out and signed by a Physician***

Tetanus - _______________________                     Rubella - _______________________

Mumps - _______________________                      Poliomyelitis - _______________________

Diphtheria - _______________________                  Measles - _______________________

Chicken Pox - _______________________               Pneumonia - _______________________

Other - _______________________                        Other - _______________________

Doctor’s Name Printed___________________________    Office Address_______________________

Doctor’s Signature ________________________________  Office Phone # ____________________