Summer Camp Health Form

Camper

Camper First Name *

Camper Last Name *

Address

Address *

Country *

Address 1 *

Address 2

City *

State *

ZIP code *

Emergency Contact

1st Emergency Contact *

(Parent or Legal Guardian Name)

Phone number: *

Email address: *

2nd Emergency Contact *

(Other than parent above)

Phone number: *

Email address: *

Child Primary Care Physician: *

(or other provider of medical care)

Primary physician phone number: *

Health Information

Does the camper have any health problem including physical, psychiatric or behavioral problems of which we need to be aware? *

Please explain any health problem and any considerations: *

Does the camper have any medications, dietary restrictions, allergies or special needs that we need to be aware of to ensure that your child’s camp experience is positive? *

Please explain: *

Does the camper have an IEP or 504 plan in place in his/her regular weekday school? *

Please explain: *

Immunization Form

Is this child exempt from any immunization because of a parental or guardian objection or medical contraindication? *

If Yes, please list them: *

For campers who reside outside the United States ONLY : Please complete Department Form DHMH-896 and send it by email

(Form DHMH-896 is the record of vaccination or immunity of the camper. It can be uploaded here: https://phpa.health.maryland.gov/OIDEOR/IMMUN/Shared%20Documents/MDH_896_form.pdf)

Signature

Please type your name here as signature of the form above: *

Form should be completed by parent or legal guardian.

Email address of the person filling out the form: *