CAMP WACHUSETT
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HEALTH INFORMATION
Be sure to fill out both the health AND emergency forms -- provided below.

Please complete online, print, sign and return by mail (signature required in two places).


Name of camper:   Date of Birth:

Blood Pressure:   Weight:   Height:

DATE OF LAT FULL PHYSICAL

Medical History (for positive findings)

Allergies:

Contact Seizures
Food Fractures
Insect Heart problems
Medicines Headaches
Pollens Joint disease
Needs Epipen ADD/ADHD
Asthma -
uses inhaler		 Stomach problems
Chicken pox Ear problems
 

MEDICINES TAKEN REGULARLY:

 

MEDICINES ALLERGIC TO:
Penicillin: Yes   No
Others:

IMMUNIZATIONS TO DATE (Exact dates, please, not "up-to-date" or "current")

Date of MMR 2nd dose (Boys entering 6th grade or above should have 2nd MMR)

Date of last Tetanus Date of last TB test   Pos. Neg.

Your signature below authorizes the camp nurse to dispense the following over-the-counter medications:

Tylenol Advil Benadryl (liquid and tablet)
Dimetapp Calagel CortAid .5% creme
Robitussin Neosporin Medicaine Stingese
Hall's coughdrops Isotonic eye irrigating solution

 

 

Signature: ____________________________  Date: ______________

If your son is to receive prescription medications, uses an inhaler, or needs an Epipen, please enclose a written order from your physician and send the medications in the original pharmacy-labeled container.  No prescription medications will be dispensed unless they are in a pharmacy-labeled container.

 

EMERGENCY INFORMATION
(Please complete, print, sign and return by mail -- signature required)

Names of parents (including first names):

Home address:
                       

Home phone:   Car phone:

Father's employer:   

Address:

State:    Zip:

Business phone:

Mother's employer:   

Address:

State:    Zip:

Business phone:

Persons to call in an emergency if you cannot be reached:

Name:   Phone:

Name:   Phone:

Name of camper's doctor:

Address:

Phone:

Medical Insurance Co.   Certificate # Code

 

I hereby give my permission to James Weiss, Maria Weiss, or other Camp Wachusett personnel in charge to take necessary medical action in emergency situations for my child when I am not immediately available.

Signature ___________________________________

Soc. Sec. # _________________________________

Date _______________________________________

Please print and mail to:

CAMP WACHUSETT CO.                             PHONE NUMBERS:
James Weiss                                                    (301) 933-1709
11112 Waycross Way                                      1-800-847-9763
Kensington, MD  20895                                  FAX NUMBER: (301) 933-0453

Please complete online, print, sign and return
 by mail -- signatures required!

Home | Contact Directors | Features, Facilities & Photographs | What's New?