Health History Textarea* Textarea* Family Physician* Phone Number Checkbox* Insect Stings Heart Condition Frequent Colds Bee stings Drugs Chronic Asthma Other Allergies Hay Fever Diabetes Physical Handicap Epilepsy Headache Frequent Stomach Upsets Chronic Bronchiti Chronic Respiratory Infections Other If other, List here Date of last tetanus immunization Date of last booster Date of last T B Test Are your child`s immunization shots up to date? Yes No Any recent operation, injury, or illness? Yes No Please explain and indicate date* Allergic reactions to food, environment, or medicine? Please LIST ALL MEDICATIONS that will be sent with your child to camp. This should include prescription (i.e., Inhalers) and over the counter medications (i.e, Tylenol, cough syrup, etc.) Also please check medications that you approve for our RN to administer to your child(ren) if needed while at camp* Pain (Panadol Brufen) Fever (Paracetamol, Brufen) Eye/Ear (Drops) Stomach (Zinc, Buscopan, Floranol) Cold Medications/Allergy/Cough Syrups (i.e., Piriton, Bro zedex Expectorant) Other If Other, Provide details Child’s Name Submit
+254 717 78 78 07