Camper Health History

AFTER SCHOOL KARATE ACADEMY

    Child's Name:

    The following information is required:

    1st Emergency Contact (Parent or Legal Guardian):

    Phone:

    2st Emergency Contact (Parent or Legal Guardian):

    Phone:

    Child's Physician:

    Phone:

    HEALTH INFORMATION:

    1. Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?NO

    Yes Explain

    2. Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be awareAre there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive?NO

    Yes Explain

    IMMUNIZATION INFORMATION:
    OR

    For campers who reside within the United States. a United States territory, or the District of Columbia:

    1.State/territorty in which child resides:

    2.Is this child exempt from any Immunizations?

    NOYES, List them

    For campers who reside outside the United States, a United States territory, or the District of Columbia:

    1.Country in which child resides:

    2. Attach Department form DHMH-896 (record of vaccination or immunity)

    Parent or Legal Guardian's Signature:

    date