Rainbow's End Camper Medical Info

Rainbow's End Camper Medical Info

Camper Medical Information

Rainbow's End Day Camp
Camper's Name*

First NameLast Name
Camper's Date of Birth*

MonthDayYear
Date
Age at Camp*
Medical Diagnosis*
Height*
Weight*
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Drug Allergies*
Non-Drug Allergies*

Are there any concerns with the following? If yes, please explain:

Rows	No	Yes	Explain
Ears
Nose
Throat
Skin
Eyes
Heart
Lungs
Extremities
Abdomen
Genitalia

Any history of the following? If yes, please explain:

Rows	No	Yes	Explain
Asthma
Recent Illness
Kidney Disease
Diabetes
Stomach Disorder
Hay Fever
Hepatitis B or C
Heart Disease
Recent Surgery
HIV
Other