Medical Information Form

Please click with your mouse all the correct yes/no buttons
then print out, sign and date below and
mail in with your completed application.


Last Name:

MEDICAL BACKGROUND	CHILD #1	CHILD #2	CHILD #3
Enter your child's first name
CURRENT HEALTH CONDITIONS:
Epilepsy/Convulsions	Yes No	Yes No	Yes No
Heart Defect/Disease	Yes No	Yes No	Yes No
Diabetes	Yes No	Yes No	Yes No
Bleeding/Clotting Disorder	Yes No	Yes No	Yes No
Asthma	Yes No	Yes No	Yes No
Other	Yes No	Yes No	Yes No
MY CHILD'S IMMUNIZATIONS/VACCINATIONS ARE CURRENT FOR:
Chicken Pox (Varicella)	Yes No	Yes No	Yes No
MMR (Measles/Mumps/Rubella)	Yes No	Yes No	Yes No
DPT (Diphtheria/Tetanus/Pertussis)	Yes No	Yes No	Yes No
HIB (Hib Meningitis)	Yes No	Yes No	Yes No
Hepatitis B	Yes No	Yes No	Yes No
Polio	Yes No	Yes No	Yes No
SERIOUS ALLERGIES:
Insect Stings	Yes No	Yes No	Yes No
Penicillin	Yes No	Yes No	Yes No
Other Drugs	Yes No	Yes No	Yes No
Food	Yes No	Yes No	Yes No
Other	Yes No	Yes No	Yes No
Please comment on "Yes" answers to current Health Conditions or Allergies
Medications that must be administered at camp
EMERGENCY AUTHORIZATION

I, the undersigned parent / guardian of said minor, do hereby certify that my child(ren) is (are) physically and mentally able to participate in camp activities. In the event of illness or accident I hereby grant full authority to the Art Camp to take whatever actions it may consider to be warranted under the circumstances regarding the health and safety of my child(ren). Such authority shall include the power to consent to any X-ray examination, anesthesia, medical or surgical diagnosis or treatment, and hospital care under the supervision of a licensed medical practitioner, or to consent to an X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered by a licensed dental practitioner. Any such diagnostic treatment or care shall be rendered at my expense. In the event of injury or illness I understand that due effort to contact me to assist in any decision will be made by the Art Camp, but that said Art Camp will be compelled to use its best judgment should it not be possible to contact me. I hereby indemnify the Art Camp and any director, teacher or counselor from any liability because of the exercise of such consent.

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Signature of Parent or Guardian

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Please Print Parent's or Guardians Full Name

__________________
Date