Children's Summer Camp Excursion Health Declaration Form
Child's Full Name
Age
Date of Birth
Parent/Guardian Name
Emergency Contact Number
Does your child have any allergies?
Yes
No
If yes, please specify
Does your child take any medication regularly?
Yes
No
If yes, please list medication(s) and dosage
Does your child have any medical conditions or physical limitations?
Yes
No
If yes, please specify
Date of last tetanus shot (if known)
Doctor's Name
Doctor's Phone Number
Any additional health information or special instructions
I hereby declare that the information provided above is accurate and complete to the best of my knowledge.
Parent/Guardian Signature
Date