Health History Form for CPA's
First Name (*)

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Last Name (*)

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Your Camp Name (*)

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Birthdate (mmddyear) (*)

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Age (xx) (*)

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Name of parent/ guardian:

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Parent/Guardian's Day Time Phone Number

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Authorization for Treatment: In the case of an emergency, I hereby give permission to the physicial selected by the camp director to secure and administer treatment, including hospitalization for my child named above.



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In an Emergency Notify: (*)

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Relationship to you (*)

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Day Time Phone Number xxxxxxxxxx (*)

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In an Emergency Notify: (*)

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Relationship to you (*)

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Day Time Phone Number xxxxxxxxxx (*)

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Medical Insurance

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ID Number

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Name of Primary Care Physician (*)

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Phone Number xxxxxxxxxx (*)

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Date of last physical exam (mmyear) (*)

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Health History: check those that apply

Diseases (*)






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Allgergies (*)










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Explanation of Allergy to:

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Chronic or Recurring Illness (*)












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Explanation of Chronic or Recurring Illness:

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Please describe conditions and dates

Operations or serious injuries

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Hospitalizations

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Other diseases or disabilities

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List all medications you take regularly

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for what condition?

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Please comment where applicable:

Are there any additional concerns, medical or otherwise, you wish to bring to our attention?

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Please make sure all information is correct before clicking on the submit button.


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