LCA Summer Camp Health Form

Student Information

Today's Date*

Answer required for "Today's Date"

Student's First Name*

Answer required for "Student's First Name"

Student's Last Name*

Answer required for "Student's Last Name"

Student's Date of Birth*

Answer required for "Student's Date of Birth"

Gender*

Answer required for "Gender"

Male

Female

Grade Entering*

Answer required for "Grade Entering"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip Code*

Answer required for "Zip Code"

Child Lives With:*

Answer required for "Child Lives With:"

Parent/Guardian 1 Information

Name*

Answer required for "Name"

Phone Numbers: Work/Cell/Home*

Number Required

Email Address*

Answer required for "Email Address"

Relationship to Child*

Answer required for "Relationship to Child"

Parent/Guardian 2 Information

Name

Answer required for "Name"

Phone Numbers: Work/Cell/Home

Number Required

Email Address

Answer required for "Email Address"

Relationship to Child

Answer required for "Relationship to Child"

Emergency Information

Doctor's Name*

Answer required for "Doctor's Name"

Doctor's Phone Number*

Number Required

Date of Last Physical Exam*

Answer required for "Date of Last Physical Exam"

Preferred Emergency Care Facility*

Answer required for "Preferred Emergency Care Facility"

Dentist's Name*

Answer required for "Dentist's Name"

Dentist's Phone Number*

Number Required

Date of Last Dental Check-Up*

Answer required for "Date of Last Dental Check-Up"

Student Health Information

Please explain any "Yes" answers from above

Answer required for "Please explain any \"Yes\" answers from above"

Describe any other important health-related information about your child

Answer required for "Describe any other important health-related information about your child"

List all prescription, over-the-counter, and herbal medications your child takes regularly

Answer required for "List all prescription, over-the-counter, and herbal medications your child takes regularly"

Do you give permission for your student to use hand sanitizer? *

Answer required for "Do you give permission for your student to use hand sanitizer? "

Yes

Do you give permission for your student to use sunscreen? *

Answer required for "Do you give permission for your student to use sunscreen? "

Yes

Please fix the highlighted areas below before submitting.

LCA Summer Camp Health Form