Medical Information (Step 3)

STEP 3:
Please fill out this form for each child attending camp and click Submit.

Childs Name

Parent or Legal Guardian

Parent or Legal Guardian Email

This address will receive a confirmation email

Statistics

Height

Please select one option.

3' 6 3' 7 3' 8 3' 9 3' 10 3' 11 4' 0 4' 1 4' 2 4' 3 4' 4 4' 5 4' 6 4' 7 4' 8 4' 9 4' 10 4' 11 5' 0 5' 1 5' 2 5' 3 5' 4 5' 5 5' 6 5' 7 5' 8 5' 9 5' 10 5' 11 6' 0 6' 1 6' 2 6' 3 6' 4 6' 5 6' 6

Weight

Medical Conditions & History

Disabilities & Restrictions

Behavioral Problems (please explain)

Past Diseases

Please select all that apply.

Chicken Pox Rubella Heart Disease Measles Rheumatic Fever Asthma Mumps Convulsions Ear Problems

Immunization Record

Upload Shot Records

Upload (8MB)

** Note: Immunization records from previous years are on file. If, however, the child has received any immunizations in the last year, please note it.

You do not have to fill in the blanks if you attach immunization records.

Hepatitis B (Dose 1)

Hepatitis B (Dose 2)

Hepatitis B (Dose 3)

Measles, Mumps, Rubella (MMR) (Dose 1)

MMR (Dose 2)

Diphtheria, Tetanus, Pertussis (DTaP or DTP) (Dose 1)

DTap or DTP (Dose 2)

DTap or DTP (Dose 3)

DTap or DTP (Dose 4)

DTap or DTP (Dose 5)

H. Influenza type B (HiB) (Dose 1)

HiB (Dose 2)

HiB (Dose 3)

HiB (Dose 4)

Polio Vaccine (Dose 1)

Polio Vaccine (Dose 2)

Polio Vaccine (Dose 3)

Polio Vaccine (Dose 4)

Varicella (Chickenpox) (Dose 1)

Varicella (Chickenpox) (Dose 2)

Tetanus-Diphtheria (Td) Last Immunization Only

Description

STEP 3:
Please fill out this form for each child attending camp and click Submit.

Medical Information (Step 3)

Description

Please Fix the Following