SHEN SUMMER ADVENTURES 2008

HEALTH FORM

Please complete the following form and submit with your registration for any of our Shen Summer Adventures Camps.  We require only one medical form per child.

Name___________________________________________Grade Entering_____

What school did your child attend last year?____________________________________

Address_________________________________________________________________

Birthdate ___________

Camp Name(s) & Week Attending____________________________________________

________________________________________________________________________

Parent/Guardian__________________________________________________________

Daytime Phone_____________Evening Phone_____________Cell Phone____________

Emergency Contact Person______________________________________________Phone_______________

Does the student require an aide during the school year? Yes___  No___

*Daily Medications_______________________________________________________

*If medication is to be given during Shen Summer Adventures, we must have written permission from the parent and the physician.  The medication must be in the original prescription container.

Please indicate any other health concerns______________________________________

________________________________________________________________________

Student’s Physician_________________________________________Phone__________

If the student will be picked up by someone other than the above mentioned parent/guardian please submit the name of that person below.

Name____________________________________________________Phone__________

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