216 North Street East,
P.O. Box 602
Talladega, AL. 35161
Print this form then fill them out and bring it with you on
July 2nd.
HEALTH
HISTORY AND EXAMINATION FORM
for
Children and Youth
Bring to:
Shocco Springs
P.O. Box
886
Talladega, AL 35161-0886
Name ______________________________________________ Birthdate _______________
Age _______ Sex ________
Last First Middle
Parent/Guardian or Spouse__________________________________________________ Home Phone_____________________
Address__________________________________________________________________
Work Phone _____________________
Street and Number City State Zip
In Emergency Notify______________________________ Address ______________________________ Phone_____________
Dates to be at Camp___________________ Name and Address of Group____________________________________________
══════════════════════════════════════════════════════
HEALTH HISTORY (Check - Give approximate dates)
Diseases Allergies* If yes, please give full details
Frequent Ear Infections_________________ Chickenpox_______________ Hay Fever, Etc._________________
Frequent Colds/Sore Throats_____________ Measles__________________ Poison Ivy/Oak/Sumac___________
Sinusitis/Bronchitis____________________ Mumps__________________ Insect Stings____________________
Strep Throat__________________________ German Measles___________ Penicillin______________________
Mononucleosis________________________ Whooping Cough__________ Aspirin________________________
Heart Defect/Disease___________________ Tuberculosis______________ Other__________________________
Epilepsy/Convulsions___________________ Polio____________________ Food__________________________
Bleeding/Clotting Disorders_____________ Diabetes_________________ SUBJECT TO Sleep Walking___
Hypertension__________________________ Asthma__________________ Bedwetting___ Fainting___
Stomach Problems______________________ Arthritis_________________ Constipation___ Other___
Other Diseases or Details of Above ____________________________________________________________________________
__________________________________________________________________________________________________________
Recent Exposure to Contagious Disease_________________________________________________________________________
Operations or Serious Injuries (describe & give dates)_____________________________________________________________
Are Immunizations up to date? _______________ If no, explain____________________________________________________
Date of Last Tetanus Shot ___________________ Date of Last TB Skin Test_________________________________________
Any Swimming, Diving, or Activity Limitations?_________________________________________________________________
Any Special Medical or Dietary Regime to be Continued?__________________________________________________________
Current Medications ________________________________________________________________________________________
Any Specific Activities to be Encouraged?_______________________________ Restricted?_______________________________
Name of Family Physician_________________________ Address & Phone _________________________________________
Suggestions for Shocco
Personnel______________________________________________________________________________
_________________________________________________________________________________________________________
IMPORTANT - THE
INFORMATION BELOW MUST BE COMPLETED FOR ATTENDANCE
The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted.
Emergency Authorization - I hereby give permission to the medical personnel selected by Shocco's Executive Director/Nurse to order X-rays, routine tests and treatment for my child. In the event of an emergency and I cannot be reached, I hereby give permission to the physician selected by Shocco's Executive Director to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery for my child as named above.
I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company.
__________________________________
____________________________ __________
Signature
of Parent/Guardian
Witness
Date
I
_________________________ understand and agree to abide with the
restrictions placed on my activities by
Name
by my parent/guardian.
________________________________________
Signature of Child/Youth Participant
INSURANCE
(Verify
accuracy of insurance information - Insurance carrier's address is
essential.)
Insurance issued
in the name of:
______________________________________________________________
Address of
insured:
_________________________________________________________________________
Street or Box
City State Zip
Date of Birth of
Insured:____________________ Is this coverage for a dependent?
_____________
If so, give name
of dependent:______________________________ Relationship:
____________________
Name of
Insurance Company:
_________________________________________________________________
Address of
Insurance Company:
_______________________________________________________________
Street or Box
City State Zip
Telephone
Number: _________________________ Policy Number:
__________________________
Please attach, if available, a photocopy of both sides of your health insurance card.
I understand that my insurance will be filed as the primary carrier. In the event that no insurance is provided by the family, Shocco Springs Medical Supplement will be the primary within the prescribed limits.
___________________________________
Signature of Parent/Guardian