| Petra Camp Medical Form Personal Health and Medical Record Church Name _______________________________________________ Height Weight Eye Color Hair Color |
| To be filled out by parent, guardian, or adult participant. Please print in ink. INDENTIFICATION Name DOB age Sex Name of parent or guardian telephone Address If person about is not available in the event of an emergency, notify Name Relationship Telephone Name of personal physician Telephone Personal health / accident insurance carrier Policy No Can your child swim Yes No Do you give your child permission to swim at camp? Check all itmes that apply, past or presnet, to your health history. Explain any "Yes" answers. ADHD ( Attention-Deficit Hyperactivity Disorder) Convulsions/seizures Asthma Diabetes Cancer/leukemia Heart trouble Hemophillia High blood pressure Kidney disease Other Explain Camp Nurse may administer Tylenol Advil Benadryl List any medicaitons to be taken at camp, including drug, dosage, route (oral, injection, etc.), and frequency: Medication must be registered with the principal, his/her designee, or the school nuse. It must be in the original container and be properly labeled with the student's name, prescriber's name, date of prescription, name of medication, dosage, strength, time interval, route of administration, and the date of drug's expiration when appropriate. |