Medical Form

Step 3


Please complete steps one & two of the registration process before filling out this form.


 
 

Don't forget to hit the SUBMIT button once you have complete the form.  Thank you!

Name of attending witch or wizard *
Name of attending witch or wizard
Birthdate *
Birthdate
Parent/Guardian #1 *
Parent/Guardian #1
Best phone *
Best phone
Parent/Guardian #2
Parent/Guardian #2
Best phone
Best phone
Emergency contact other than parent/guardian *
Emergency contact other than parent/guardian
Best phone *
Best phone
Name of Physician *
Name of Physician
Physician phone number *
Physician phone number
Do you have medical insurance? *
Name of insured
Name of insured
Is an Epipen necessary *
Date of last tetanus booster
Date of last tetanus booster
We intend to be sensitive to and meet the unique needs of your child to the best of our ability and can only do so if we have the information that would assist us .
Parent/Guardian /Staff Authorization: This health history is correct and complete as far as I know, and the person herein described has permission to participate in all camp activities except as noted. 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/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization for the person named above. This form may be photocopied for trips outside of camp. *
Digital Signature *
Digital Signature
By typing in your name, you are providig a digital signature.
Date Signed *
Date Signed

Congratulations! If you have done ALL THREE STEPS below, your registration is complete!