Summer Camp Physical Form

Participant Information

Age

Participant Name

Leslie Holden

leslie.h@noemail.com

Date of Birth

March 25, 2008

Phone Number

(123) 123-4567

School Name

ABC School

Address

3670 West Fork Drive

Hallandale Beach, FL, 33009

Parent/Guardian Information

Name 1

Vanessa Smith

Relationship

Mother

Phone Number

(123) 123-4567

Name 2

Kelvin Marler

Relationship

Father

Phone Number

(123) 123-4568

Name	Primary Number	Secondary Number
Kelvin Marler	123 123-4567	123 123-4560
Vanessa Smith	123 123-4568	123 123-4561

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Summer Camp Physical Form

Health Insurance

Company Name

ABC Insurance

Policy Number

1234567

Policy Name

All Covered Insurance

Health/Medical Information

Weight (kg)

Height (cm)

160

Assessment

	Status	Description
EENT	Normal
Heart	Normal
Chest	Normal
Lungs	Normal
Reproductive	Normal
Neurological	Normal
Skin	Normal
Bones	Normal

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Summer Camp Physical Form

Health/Medical Information

Name of Medication	Purpose
Vitamin C	Vitamins

Does the client have any allergies? If yes, please list them below:

None.

Does the participant wear any implantable medical devices? If yes, what are these devices?

Was the participant previously hospitalized? If yes, please indicate when and why:

No, the participant was never admitted to the hospital.

Did the participant undergo any surgery in the past? If yes, please indicate the name or location of the surgical procedure:

No, he/she did not go on any surgery.

Does the family have a family history of the following medical diagnosis?

Cardiovascular disease

Does the participant have any of the following conditions:

Asthma

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Summer Camp Physical Form

Immunization History

	Vaccinated?	When?	Scheduled Booster
Measles	Yes	2010	2010
Mumps	Yes	2010	2010
Pertusis	Yes	2010	2010
Rublella	Yes	2010	2010
Polio	Yes	2010	2010
Tetanus	Yes	2010	2010
HIB	Yes	2010	2010
Hepatitis B	Yes	2010	2010
Diptheria	Yes	2010	2010
Chickenpox	Yes	2010	2010

ACKNOWLEDGMENT & RELEASE

I authorize ABC Camp to provide medical treatment performed by the medical staff in the camp if required.
I authorize ABC Camp to carry out emergency measures like first aid, CPR, and medications as needed.
I release ABC Camp for any liability, damage, or cost that can happen like accidents or injuries during the summer camp.

Parent/Guardian Signature

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About this template

A Summer Camp Physical Form is a document that is used by the camp organizer to assess the participant's health status. It is important to identify the medical condition or needs of the camper because this will help the organizer adjusts in the situation or strategize ahead of time. This document is also a requirement for every camper because this will help the camp's medical team to implement a plan of care or if an emergency happens. This form will also determine if the camper is fit to participate in the camp or what specific programs the camper can only join to.

This Summer Camp Physical Form shows the participant information, parent or guardian details, health insurance, current and past medical data of the camper, immunization history, and acknowledgment. This template is using the Input Table tool to display the health assessment and immunization history in a table format. You can further customize this template by changing the color theme, font format, or layout via the PDF Editor.

Categories

Details

559 Clone

Created by

KateAndrew

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