**Email*
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*Home Address*
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*City*
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*State*
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**Zipcode*
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*Gender*
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**Home Phone*
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**Birth Date*
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| Camper Information |
| Medical Emergency Contact Information |
| Person to contact first: |
| Backup contact (relative or friend): |
Name
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Relation to Camper
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Daytime Phone
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Evening Phone
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Name
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Relation to Camper
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Daytime Phone
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Evening Phone
|
| Directions: This form must be completed and signed by both parent/legal guardian and physician and is due in our office one week before check-in or the camper will be unable to participate. |
| List |
Any allergies (Food, Drugs, Plants, Insect Bites) or dietary restrictions (If life threatening allergies, you will need to arrive at camp with, and know how to use an Epi-Pen):
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Other health problems:
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Medications the camper is currently taking:
|
| Please note: our staff cannot administer any medications, prescription or non-prescription, to campers. This includes over-the-counter medicines liek Advil and Tylenol for minor headaches or pains. If the camper will need to take medications while attending our program, she/he must bring the medication to camp and assume responsibility for taking it as needed or indicated. |
Parent/Guardian Initials
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Date
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Medical History
");
document.write("Immunization Dates: |
Are all immunizations up to date?
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Last Tetanus (DPT or TT or TD)
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Date of last medical checkup
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| Physician\'s Permission/Information |
| ");
document.write(" I have examined the above-named camper within 12 months prior to his/her camp session and found him/her to be free from infectious and contagious disease and qualified to fully participate in all activities of the Cliff Drysdale FGCU tennis camp. ");
document.write(" |
Physician\'s Initials
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Date
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Physician\'s Name
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Address
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City, State, Zip
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Telephone
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*First Name*
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*Last Name*
|