Medical Release

2024 Medical Release

Thank you for registering for our 2023 camps! Please fill out one medical form per child participating. You can make changes and resubmit this form at a later date if needed.

Contact

Participant Name

Participant Date ofBirth

Participant's Gender

Address

Parent/Primary Contact Name

Primary Contact Email

Primary Contact Phone

Secondary Contact Name

Secondary Contact Phone

Medical Insurance and Physician

Name of participant's medical nsurance provider and group plan number.

Personal/Family Physician

Physician Phone

Medical History

Date of last tetanus booster

Does the participant have any medical conditions, illnesses, disabilities, limitations, or allergies?

Does the participant take any medications?

Does the participant have any special food needs?

Has your child ever been stung by an insect? If so, please explain what stung them and if there was an allergic reaction.

Our policy is to administer Children's Benadryl internally if a child is stung by an insect such as a yellow jacket and has never been stung before or if there is a known potential allergy. If a child is very distressed and in pain from the sting, but has not had an allergic reaction from past stings, we will apply the liquid Benadryl to the sting topically. If a child is in severe pain (for example from a migraine) we will call parents before administering Children's Ibuprofen. Please write "yes" below if you consent to this policy. If you have other wishes for your child's care, please explain below. Thank you!

Do you consent to the above?

By signing below, I acknowledge that the information I have provided on this form is accurate and up to date. I will be responsible for resubmitting this form, if changes occur, to ensure that Greenwood staff have accurate and up-to-date medical information regarding the participant.

Your Signature

Your form has been submitted. Thank you!