Allergy Health History Form
This form must be returned before the student arrives. Please be as thorough as possible. This information is a supplement to the health history which will be submitted to the Academy.

Part One - Parental Authorization

I understand and certify that my child's participation in the spring / summer camp program is completely voluntary. I understand that certain hazards and dangers are inherent in the camp program, and I acknowledge that although The Thinnox Academy has taken measures to minimize the risk of injury to camp participants, The Thinnox Academy cannot guarantee that the activities will be free of accidents or injuries. Furthermore, I have instructed my child in the importance of abiding by the camp's rules and procedures for the safety of camp participants.

I understand that parents are contacted in the event their child receives professional medical attention. In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the Thinnox staff to secure professional treatment for my child.

Date Date Month Year
Student's name Last name
  First name
  Middle name
Camp Name
Camp Date
Parent Name
Phone Number
Student's Healthcard No.*
If you have a family physician please provide:
Family Physician Name
Doctor's Office Number
 

Part Two - Health Information
Basic Health History:  
bleeding disorders epilepsy
sleepwalking
Allergies:  

Immunizations:  All immunizations must be up to date.  Indicated dates of basic immunization or most recent booster.
DPT Polio
Measles Current tetanus
If date cannot be supplied, please initial this statement: "In case of an emergency, the attending physician may administer a tetanus booster."
Operations, Serious or Chronic Illnesses:
Dietary Modifications While At Camp:
Prescription Drugs Camper Brings to Camp: (include instructions)

Part Three - Health Examination Record
This health history record is correct so far as I know, and the person herein described has permission to engage in all prescribed camp activities except as noted by me. I also attest that the person herein described has had a medical examination within the past 24 months.