Camp Thurman

Camper's Full Name:

1. Does the camper have any allergies to non-prescriptive medicines?

yes no Which?

2. Is the camper allergic to anything which might be encountered at camp?

yes no Explain

3. Is the camper under any special medication or diet?

yes no Explain

4. Are there any special problems which would effect activities at camp?

yes no

Check any of these which apply

	Diabetes		Hyperactivity
	Epilepsy		Hay Fever
	Asthma		Other

Explain other problems

5. Are the camper's immunizations current?

yes no

Please list the dates of the latest immunizations:

	DPT		MMR
	HEP B		OPV

6. Are there any restrictions on the camper's activities at camp?

yes no Explain

7. If needed to relieve pain, fever or allergic reaction, may we have your consent to administer

a non-aspirin product (acetaminophen)?	yes no
an allergy reliever (benadryl)?	yes no

8. Doctor's Name		Telephone
Insurance Company		Group#

9. Please READ, DATE, AND then click AGREE or CANCEL.
In case of medical emergency, after every reasonable effort has been made to contact parent or guardian, I hereby give permission to the physician selected by the camp director to secure necessary diagnosis and treatment for the child herein described. I have not been given a guarantee of the results of examination or treatment.

10. I also give permission for photos of my child at camp to be used in the brochure or on the website.

Signature of Parent or Legal Guardian
DATE

By entering your name above and clicking "AGREE", you are giving us a "digital" signature and confirming the medical
information and signing the release for medical treatment.

Pantego Camp Thurman, 3001 Sarah Dr., Arlington, TX 76013
817-274-8441 Fax: 817-274-2316
E-mail: campthurman@sbcglobal.net or campthurman@campthurman.org

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