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Camp Commotion Health History & Examination Form General Information` Name___________________________________________Birth Date________________Age___________________Grade in Fall_____________________ Home Address________________________________________________City________________________________Zip Code________________________ Parent/Legal Guardian___________________________________________________________________________________________________________ Phone Number_____________________________Cell Number_____________________________Work Number__________________________________ Business Address______________________________________________Work Number_______________________________________________________ Second Parent/Legal Guardian_____________________________________________________________________________________________________ Phone Number_____________________________Cell Number_____________________________Work Number__________________________________ Address (if different than above)________________________________City________________________________Zip Code________________________ If a parent is not available in an emergency, notify: Name__________________________________________________________________________________________________________________________ Relationship____________________________________________Phone Number____________________________________________________________ Address______________________________________________________City_______________________________Zip Code________________________
Insurance Information Is the participant covered by family medical/hospital insurance? Yes or No If so, indicate carrier or plan name_________________________________Group #________________________________ Carrier Address____________________________________________City__________________Zip Code_______________ Name of Insured______________________________________Relationship to participant___________________________
Health History The parent/legal guardian must fill in the following information. The intent of this information is provide camp personnel the back ground of appropriate care. Keep a copy of the completed form for your records ALLERGIES-List all known
Describe Reaction and management of the reaction
Medication Allergies (List) ___________________________________
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Food Alergies (List) ___________________________________
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Other Allergies (List) - include insect stings, hay fever, asthma, animal dander, etc. ___________________________________
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Medical Conditions –list any conditions that we need to be made aware of _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________ *if medication/epi pen is required, separate forms must be filled out