Health Form – Surf Hatteras

Medical Form Entries

Camper First Name

Camper Last Name

Parent First Name

Last Name

Select Week(s)

Allergies & Dietary Needs

Please fill out every field

Dietary Allergies/Restrictions

Other Allergies

Will you be sending an epi pen for your child?

Yes

Camper Health History

Please fill out every field

Has the participant ever had a bleeding/clotting disorder?

Yes

Does the participant have a seizure disorder?

Yes

Does the participant have any physical impairments?

Yes

Does the participant have diabetes?

Yes

Does the participant have asthma?

Yes

Does the participant have problems with fainting or dizziness?

Yes

Does the participant have any restrictions (physical, mental, or behavioral) to participating in activities?

Yes

If you said "YES" to any of the above, or if your child has any other pertinent medical issue, please explain below.

Medications

Please list any medications your child will be taking during camp (including dosage and any special instructions).

Health Care Authorization:

As the Participant's parent or guardian, I certify that the information stated on this form is complete and correct. I give permission to the Surf Hatteras staff to provide appropriate first aid for minor injuries and to seek further treatment from local emergency personnel, physicians or hospitals if the medical condition warrants. In the event I cannot be reached in an emergency, I also give permission to the treating physician to examine, diagnose, and treat or secure proper treatment for the Participant and hospitalize, and to order injection and/or anesthesia and/or surgery for the Participant, as the physician shall determine proper and necessary under the circumstances. I agree to assume full financial responsibility for the costs of any evacuation and/or medical treatment that the Participant may receive.

Yes, I agree to all