Medical Form

Camper Name______Date of Birth______

Parent/Guardian Name______Phone______

Parent/Guardian Name______Phone:______

Medical Insurance Information:

Company Name:

Policy Number:

Contact Phone Number (if applicable):

Allergies

Include medicines, foods, animals, insect bites and stings, and environment (dust, pollen, etc.).

Allergy / Reaction / Medication Required

Medical History

Please list all prescription, over-the-counter, and natural medications your daughter is taking.

Medication Name / Dosage / Frequency / Side Effects / Reason for taking

Recent illness?

Accidents, operations, hospitalizations?

Does your daughter have asthma? _ Yes _ No If yes, please list any medications above.

Does your daughter have diabetes? _ Yes _ No If yes, please list any medications above.

Does your daughter have a history of high blood pressure? _ Yes _ No

Does your daughter have any bone, joint, or muscle problems? _ Yes _ No If yes, please explain below

Has your daughter ever had a seizure? _ Yes _ No If yes, please explain on a separate sheet.

Does your daughter have any other medical issues that we should know about? _ Yes _ No If yes, please explain below.

Physical Examination

Date of most recent physical:

Physician's name:

Address:

Phone Number:

Please notify Hanger Hall immediately if any information on this form changes.

Camp Hanger Hall OTC Medication Form

Student’s Name ______Age _____ Allergies ______

The medications below may be administered to my child during a regular school day or on a school trip at the discretion of the Hanger Hall staff. Student age and weight will be factored into the appropriate dose. PLEASE CROSS OUT ANY MEDICATION NOT TO BE ADMINISTERED.

Tylenol (or the generic equivalent) Antibiotic ointment Sunscreen

Advil (or the generic equivalent) Hydrocortisone cream

Throat/Cough Drops Tums or Pepto

**** I release The Hanger Hall School and its personnel of any liability related to the administration of the over the counter medication listed above.

Parent/Legal Guardian Signature ______Date______

Hanger Hall School Parental Consent for Medical Treatment

I hereby give permissions for Hanger Hall employees or representatives to administer and seek out form any licensed practitioner of medicine, any emergency care that my daughter, ______might need while on a field activity with Hanger Hall.

I also agree to allow Hanger Hall personnel to administer any medications that are deemed necessary for my above-mentioned daughter. Below I have listed any medications that I would not want my child to take either for physical or moral reasons.

I understand that every effort will be made to contact me before my child receives medical treatment.

Parent signature ______Date ______

Hanger Hall Summer Camp Waiver and Release

I give my child, ______permission to go on any and all field trips during (camp name and dates)______I understand that I will be adequately informed of the destination and design for each planned trip. I understand that there may be spontaneous local trips from time to time within camp hours. I understand that all care will be taken to insure the safety and security of my child. I, nonetheless, release Hanger Hall School, its officers, agents or employees from all liability for any personal property damage or loss, personal injury or loss of life on these designated official school trips.

Parent’s signature ______Date ______