Medical Form

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MUST BE COMPLETED BY PHYSICIAN Please return to the Registrar by June 2015 Please note a physical examination is good for only one year, we can not accept expired forms.

Parent's must submit the Health History Form, Authorization form, Physician's Medical Form & a copy of Immunization by June 1, 2015. NO CHILD WILL BE ALLOWED TO ATTEND CAMP WITHOUT UPDATED Physician's Medical Form on file. NO MEDICAL! NO CAMP! $25.00 late processing fee due with all medical forms not received a week before your child is due to start camp. Dear Doctor, Your patient has enrolled in a summer camp at the Science Museum of Long Island (SMLI). The summer camp will engage your patient in activities and experiments in various areas of scientific study. Activities will include outdoor activities like hiking, sports and general recreation. Please complete the form below and include any restrictions needed to keep your patient healthy and safe during their time at camp. Patient's Name___________________________________________________________________________________________________

Immunizations & boosters are up to date:

No________

D.O.B __________/__________/__________

Yes________ (polio, mmr, diptheria, tetanus, etc)

COPY OF IMMUNIZATION NEEDED AND COPY OF BIRTH CERTIFICATE NEEDED FOR NURSERY CAMPERS

Address________________________________________________________________________________________________ Phone______________________________________________________

City_________________________________________________________________

State_______________________________________

Zip________________________________________

Allergies: Medication: (example: penicillin, etc. )

No______

Yes______

Which ones and how manifested? _________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________ Insects: (example: bee sting, etc. )

No_______

Yes______

Which ones and how manifested? __________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________ Inhalents: (example: pollen, grass, etc. )

No_________

Yes_________

Which ones and how manifested? _________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________ Contact: (example: poison ivy, etc. )

No_________

Yes__________

Which ones and how manifested? __________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________ Food: (example: chocolate, peanuts, etc. )

No_________

Yes_________

Which ones and how manifested? ________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________ Does your patient have epilepsy, diabetes or asthma? ______________________________________________________________________________________________________________________ Any other patient medical conditions or information? (Attach records if needed) ___________________________________________________________________________________________ Restrictions on activity or excercise? ____________________________________________________________________________________________________________________________________ Does the patient use any medication routinely?

No_________

Yes_________

List medications: _____________________________________________________________________

PLEASE FORWARD TO: SCIENCE MUSEUM OF LONG ISLAND, P.O. BOX 908, PLANDOME, NY 11030 OR FAX: (516) 365-8927 REQUIRED: Your patient MUST have a Physical Examination within the last year to attend camp.

PHYSICAL EXAMINATION: ____________________________________________________________________ x Check if Exam Records are attached DATE of EXAM _______________________________________ Physician's Name - print

_________________________ NYS License Number

___________________________ Physician's Signature

_________________________________________ Office Address

____________ Date

__________________________ Telephone Number