Complete Skills Camp

CAMP HEALTH EXAM

Physical Exams Are Valid For 3 Years
From Date of Last Examination

Please Return Completed Form or Send Current School Physical to:

Linda Sagnelli
37 Aileen Drive
Madison,  CT 06443

Name __________________________________________

Date of Birth_________________  Phone_____________________________

Parent or Guardian Address________________________________________________________________________

Emergency Contact____________________________________________ Telephone________________________________________

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TO BE COMPLETED BY THE SPECIFIED MEDICAL PRACTITIONER:

Date of Exam_________________

________ May participate in all camp activities

________ May participate except for:

_______________________________________________________________________________

Medical information pertinent to routine care and emergencies:

_______________________________________________________________________________

_______________________________________________________________________________

Is this individual taking prescription medication?     YES      NO

If yes, indicate prescription___________________________________________________________________

Does the individual have allergies?      YES     NO     Explain:__________________________________________

Is the individual on a special diet?      YES      NO    Explain:__________________________________________

This camper is up-to-date on all the following routine childhood immunizations currently recommended by the American Academy of Pediatrics and National Advisory Committee on Immunization Practices:

Measles            YES           NO                     Hepatitis B          YES          NO

Mumps             YES          NO                       Diphtheria           YES          NO

Rubella             YES          NO                       Pertussis            YES          NO

Chickenpox      YES        NO                        Polio                    YES          NO

Tetanus             YES         NO 

Comments: _________________________________________________________________

_________________________________________________________________

Print name of medical care provider: ___________________________________________________________

Medical care provider’s address: _______________________________________________________________

Medical care provider’s: City/Town______________________________ST___________

Zip Code___________

Signature of

Physician, APRN, PA

______________________________________________________________

Date Form Signed_______________________________________________

Phone Number__________________________________________________