DICK FOSBURY TRACK CAMP HEALTH FORM

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First found May 22, 2018

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SLOVENSKI CAMPS HEALTH FORM
A copy of a camper’s school physical, complete with immunization history and doctor’s
signature, maybe substituted in lieu of this form if the physical was completed with 12 months
of the camp start date.
Camper’s Name: _____________________________________ Sex: ________ Age: _________
(Last Name)
(First Name)
Height: ________________________ Weight: ____________________
Medical History (please check for “yes”)
German Measles 
Measles 
Mumps 
Scarlet Fever 
Chicken Pox 
Diabetes 
Pneumonia 
Other: ____________________________________
Immunization History
Allergy History
Mo./Yr.
Drug Reactions
Yes No
Small Pox Vaccine ________
Diphtheria
________
Tetanus Toxoid
________
Polio Vaccine
________
Tuberculin Test
________
Measles
________
Hay Fever
Asthma
Eczema
Hives
Insect Stings










Yes No
 
 
 
Type____________
________________
Sulpha
Penicillin
Antibiotic
________________
If medication will be taken during camp, indicate name of drug and dosage:
________________________________________________________________________
________________________________________________________________________
Please list any pertinent medical information we should have regarding past injuries, past
medical history, or suggested physical limitations relating directly to the participant’s
ability to participate in the camp for six or more hours per day:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
I certify the above-named individual is able to participate fully in rigorous physical
activity, based on physical examination within 12 months prior to said camp date.
__________________________________________________________________
(Signature of Physician)
_____________________________
(Street Address)
_________________________
(Date)
_____________________________ ________
(City)
(State)
____________
(Zip)

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