Women's Camp Printable Registration Form

Women's Camp Health History Record

Camper:
Name:___________________________
Address:_________________________
State:_____ Zip:________
Birthdate :__________________

Home Phone:_______________________
Work Phone:_______________________
Cell Phone:_____________________
Email:_______________________________

Emergency Contact:
Name:___________________________
Address:_________________________
State:_____ Zip:________
Relationship:________________________

Home Phone:_______________________
Work Phone:_______________________
Cell Phone:_______________________
Email:_______________________________

Allergies:
___No Allergies ___Animals_________________________ ___Food___________________________ ___Plants__________________________ ___Hay Fever_______________________		___Medicines______________________ ___Pollen_________________________ ___Insect Stings / Bites_______________ _________________________________ ___Other (Specify)___________________ _________________________________

Health Conditions:
___Asthema	___Cardiac	___Special Dietary Needs	___Other (Specify)_______ _____________________

Please explain any items that are checked. Indicate any information useful to the person in charge in relation to any of these health conditions. Use the back of the page if more space is required.
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Please list any medications and amounts:
_______________________________________________________________________
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Name of Physician:_______________________ Telephone:_______________________
Medical / Hospital Insurance carrier:___________________________________________
Policy and / or Group # ________________________________________

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