Camper's Name:_________________________________________

Does your child have any history of allergies?__yes __no

If yes, explain:_________________________________________

List reaction(s) to past exposure:____________________________

What would you like us to do if your child is exposed?______________

____________________________________________________

If your child has medications, please list- medication name, dose, and time

taken:________________________________________________

Does your child have a medical history we should be aware of:__yes__no

If yes, explain:__________________________________________

List any over the counter medication preffered in case of headache,

stomach ache, etc.:________________________________________

List all phone numbers, in order we should call, if we need to reach you:

_____________________________________________________

I hereby authorize the camp nurse (RN, LPN, or EMT) to administer the
above mentioned medical care and prescription and/or over-the-counter
medicine to my child listed above. In case of emergency, I hereby give
my permission for emergency medical care to be administered to my
child listed above.

Signed:_____________________________________Date:___________

Relationship to camper:_____________________________________