(Please check selection.)
Please select one
Please list all mediations, prescribed and over the counter, that your child is currently taking.
Please place a check by each answer. Provide an explanation for any ‘Yes’ answer.
No known allergies
(Please list and describe reaction and management:)
(Please checked all that apply.)
The information and health history provided on this form is accurate to the best of my knowledge. The camp and camp employees shall be held harmless for any omissions or incorrect medical information provided. The child herein named has permission to engage in all camp activities as noted. It is my intention that the camp be treated as acting in loco parentis since my child is a minor. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named above. This completed form may be photocopied for trips out of the camp. I understand that a valid, signed Medication Administration Form is required for any prescription medication administered by Somerset Academy, Inc.