Medical Information Form

Emergency Medical and Release Form

Please fill out this form with your child’s most current medical information.

Please complete a separate form for each child attending

Emergency Contact Information Camper’s Name ________________________________________________ Age __________

Rising Grade __________

Parent/Guardian Names ________________________________________________________________________

Address ________________________________________________________________________

City ___________________________________________________ State ________

ZIP Code __________________

Email Address ________________________________________________________________________

Phone Number (Home)___________________________________

(Emergency) ________________________________

Other Adults Approved for Pick-up ______________________________________________________________________ ________________________________________________________________________

For your child’s safety, any adult picking up the child will be asked to show a photo ID each time the child is picked up. Thank you in advance for your cooperation.

Medical Information Check any that apply and elaborate.

Please attach extra explanation if necessary.

o Food Allergies o Environmental Allergies o Epilepsy o ADD/ADHD o Diabetes o Asthma o Heart Trouble o Seizures o Dietary Restrictions o Other Comments ________________________________________________________________________

Does the camper carry an Epi-Pen? o Yes o No

Does the camper have any special needs (learning differences, behavioral concerns, phobias, etc.)? ________________________________________________________________________

I believe the information provided above is a complete and accurate statement of the physical and behavioral factors which may affect my child’s participation in this summer camp. I hereby grant permission for my child to take part in this Summer Camp. I also agree, on behalf of myself or my child, not to make any claims of any kind against Houston Math or any of its employees or agents for any loss or injury that my child might sustain while engaged in the Summer Camp program. I authorize such physician or medical staff as Houston Math may designate to carry out any minor treatment and/or medical staff to provide any treatment deemed necessary for the well-being of my child. ____________________________________________________

 

________________ Signature of Parent/Guardian

________________ Date

PLEASE NOTE: Please return this signed form prior to the start of camp. Your child may not attend camp without a completed emergency form.