Jim Calhoun Basketball Camp

Youth Camp Health Exam/Record for Campers and Staff
Physical Exams are valid for 2 years From Date of Last Examination
Camper Staff

Name:___________________________

Birthday:_____________

Phone:____________________

Guardian: _____________________

Address:_____________________________________________

Emergency Contact:___________________________________

Phone: _____________________

Date of Arrival at Camp:__________________________ Departure Date: _____________________

To Be Completed By The Specified Medical Practitioner:
Date of Exam: ____________________

_______May participate in all camp activities

_______May participate except for: __________________________________________________________________________________

Medical Information pertinent to routine care and emergencies: __________________________________________________________________________________

Is the individual taking prescription medication? YES NO If yes, indicate prescription:__________________________________________________________________________

Does the individual have allergies? YES NO Explain:__________________________________________________________________________

Is the individual on a special diet? YES NO Explain:__________________________________________________________________________

This camper/staff is up-to-date on all the following routine childhood immunizations currently recommended by the American Academy of Pediatrics and National Advisory Committee on Immunization Practices:

	Yes	No
Measles
Mumps
Rubella
Chickenpox
Tetanus
Hepatitis B
Diptheria
Pertussis
Polio

Print name of medical care provider: _________________________________
Medical Care Provider's address: _____________________________________
Medical Care Provider's: City/Town __________________ ST ____ Zip _______________

________________________________
(Signature of Physician, APRN or PA) ________________________________
(Date Form Signed)

________________________________
(Telephone Number)