Name of attending magical student *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Best phone *

(###)

###

####

Emergency contact other than parent/guardian *

First Name

Last Name

Best phone *

(###)

###

####

Do you have medical insurance? *

Yes

No

Name of insured *

First Name

Last Name

Insurance company phone number *

(###)

###

####

Name of physician *

First Name

Last Name

Phone number of physician *

(###)

###

####

General Health History *

Please check all statements that apply

Been hospitalized

Has had surgery

Has recurrent/chronic illness

Had recent infectious disease

Had a recent injury

Has/had asthma/wheezing

Has diabetes

Has/had seizures

Has/had headaches

Wears glasses, contacts, protective eyewear

Has/had fainting or dizziness

Has passed out/had chest pain during exercise?

Has had mononucleosis during the past 12 months

Has/Had back or joint problems

Has or had issues with diarrhea/constipation

Has skin problems

Traveled outside the country in the past 9 months

None of the above

Allergies: Does you have allergies? *

No known allergies

Yes

Is an Epipen or Auvi-Q necessary? *

Yes

No

Does you use a rescue inhaler?

Yes

No

Staff Authorization: This health history is correct and complete as far as I know. In the event that I am personally unable to grant permission at the time of a medical event, I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes; and to provide or arrange related transportation for me. If I am unable to grant permission personally at the time of a medical incidient, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization for myself. This form may be photocopied for trips outside of camp. *

I have read and understood the above statement and I agree

I have read and understood the above statement and I decline.

Digital Signature *

By typing in your name, you are providig a digital signature.

First Name

Last Name

Date Signed *

MM

DD

YYYY