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MEDICAL HISTORY FORM

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POMEROY GYMNASTICS, INC.

3800 TEN OAKS ROAD

GLENELG, MD 21737

 

SUMMER CAMP 2017

MEDICAL HISTORY FORM

 


CAMPER HEALTH HISTORY



Child’s Name:___________________________________________________________________________________________________


The following information is required:


1st Emergency Contact


(Parent or Legal Guardian):                                                                                                     Phone:                                                                


2nd Emergency Contact


(Other than Parent Above):                                                                                                        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 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:


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


1. State/territory in which child resides:                                                                                 1. Country in which child resides:

    _______________________________                                                                             _______________________________

2. Is this child exempt from any                                                                                             2. Attach Department form DHMH-896
    immunizations? [ ] NO                                                                                                            (record of vaccination or immunity)
    [ ] YES, List them:                                 
                                                                 
                                                                  


Parent or Legal Guardian’s Signature:                                                                                                      Date:                                                         

DHMH-4768 (1/15)













 




 






Ċ
Jeff Pomeroy,
Mar 10, 2018, 7:06 AM
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