SAAC Camp - Summer Enrichment Program for Children

Health Form

Emergency Information/Health History
Following is a form that we ask you to fill out for each camper who will be attending SAAC this summer.

Emergency Information
Camper's First Name:
Camper's Last Name:
Primary Guardian's First Name:
Primary Guardian's Last Name:
Primary Guardian's Address:
Primary Guardian's Address:
Primary Guardian's City:
Primary Guardian's State:
Primary Guardian's Zip Code:
Primary Guardian's Occupation:
Primary Guardian's Email:

Other Guardian's First Name:
Other Guardian's Last Name:
Other Guardian's Address:
Other Guardian's Address:
Other Guardian's City
Other Guardian's State
Other Guardian's Zip Code:
Other Guardian's Occupation:
Other Guardian's Work Address:
Other Guardian's Work Address:
Other Guardian's City:
Other Guardian's State:
Other Guardian's Zip Code:
Other Guardian's Work Phone:
Other Guardian's Home Phone:
Relationship of Other Guardian to Camper:

Primary Physician's Name:
Primary Physician's Phone:
	Please check either 'Yes' or 'No' in response to the following statement. Note that checking 'Yes' consititutes an electronic signature.
	In the event that I cannot be reached in an EMERGENCY, I herby give permission to the physician selected by the Camp Direcot to hospitalize, to secure proper treatment for, and to order injection, anaesthesia, or surgery for my child as named above.


Health History
Immunizations	Please give the month and year of the basic immunization or the most recent booster. Failure to have this information on file during a Health Department inspection could result in your child being sent home.
Measles Vaccine (live)
German Measles (Rubella)
Mumps Vaccine (live)
Polio OPV (Sabin)
Diptheria, Pertusis and Tetanus
Allergies	If your child has any allergies, please check the appropriate box.
Ear Infections	Hay Fever
Rheumatic Fever	Poison Ivy
Convulsions	Insect Stings
Diabetes	Penicillin
Asthma	Physical Limitations
Other Allergies
	Please list any other allergies below, especially food allergies. Also describe all of your child's physical limitations.

	Be sure to describe below any and all details regarding your child’s health conditions that would be helpful to the camp staff: