Newport Recreation Department
Medical Form 2007
 

To help insure the safety and welfare of all children participating in the Newport Recreation Summer Day Camp and swim program, this form needs to be completed.
 
Campers Name                                                                                                        

Address                                                                                                                   

Phone#                                              Age                                 Height                    

Father's Name                                                                                                        

Home#                                   Work#                                    Cell#                           

Mother's Name                                                                                                       

Home#                                   Work#                                     Cell#                          

 
In case of an emergency please notify:

Emer Contact #1                                                 Relation:                                       

Home#                                   Work#                                     Cell#                          

Emer Contact #2                                                 Relation:                                       

Home#                                   Work#                                     Cell#                          

Insurance Company________________________ Policy #_____________

Family Physician__________________________ Phone #_____________

Family Dentist____________________________ Phone #____________

Date of last Tetnus Shot________________________________________
In the event of an emergency, we prefer treatment at:

Valley Regional___ New London Hospital___ DHMC___ Closest___ Other___
 
Medical Information (check all that apply)

Asthma___ Fainting spells___ Epilepsy___ Heart___ Diabetes___ Other____

Please explain checked items____________________________________
 
My child has difficulty with: (check all that apply)

Eyes__ Nose__ Lungs__ Car Sickness__ Ears__ Throat__ Digestion__ Other__

Please explain checked items____________________________________
 
Parent Authorization

This health history is correct to the best of my knowledge, and the person named has permission to take part in all prescribed activities unless otherwise noted below.  In the event that none of the above named relations can be reached, and only in the event of an emergency, I hereby give permission to the attending physician to treat, hospitalize, administer anesthesia, or to order injections or surgery for the safety of my child.
Signature__________________________ Date____________________
T-SHIRT SIZE:

Child:

SM___ MD___ LG          

(Check One) Adult: Small___ Medium___ Large___ Extra Large___