DOWNLOAD PDF AT BOTTOM OF PAGE
POMEROY GYMNASTICS, INC.
3800 TEN OAKS ROAD
GLENELG, MD 21737
SUMMER CAMP 2017MEDICAL 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)
| 