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Healt & Medical Information

Health and Medical Information

St. Peter the Aleut Orthodox Summer Camp

 

Complete one form per child attending:

 

 

Child’s Name_______________________________ Date of Birth ______________

 

Address ___________________________________ Grade________ M/F________

 

City_______________________________________ State _______ Zip__________

 

Parent/Guardian_______________________________________________________

 

Home Phone ____________________ Work Phone___________________________

 

Cell Phone/s_____________________  Email Address_____ ___________________

 

Emergency Contact:

 

___________________________________Contact Phone______________________

 

Medical History

 

Doctor ______________________________  Phone ___________________________

 

Address______________________________ State _______________ Zip__________

 

Insurance_____________________________ Policy Number ____________________

 

Please write and ALLERGIES your child may have in the appropriate column:

 

FOOD ALLERGIES

MEDICINAL ALLERGIES

ENVIRONMENTAL ALLERGIES

 

 

 

 

 

 

 

 

 

 

 

 

 

DOES CHILD REQUIRE ADMINISTRATION OF MEDICATION?  Yes____ No____

(If “Yes”, fill out the form that says Medical Dispensation)

 

Please write the LAST IMMUNIZATION DATE from the following conditions:

Tetanus

 

Mumps

Small Pox

Measles

Rubella

 

Polio

Whooping Cough

Diphtheria

 

 

 

¡Gloria a Dios por todo!
Direct your Questions, Comments or Feedback to (Por favor dirigir sus preguntas, dudas o comentarios al): 956-781-6114 or info@stgeorgepantry.org


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