Emergency Medical Information and Authorization

For use at Summer Camp for Penn Grove Retreat

_________________________        __________________________________
Child's Name                     Date of Birth

_________________________        __________________________________
Child's SS#                      Date last Tetanus Shot

_________________________        __________________________________
Father's Name                    Occupation

_________________________        __________________________________
Mother's Name                    Occupation

___________________________________________________________________
Home Address

___________________  __________________   _________________________
Phone #              Cell #               Work #

_________________________  _______________________
Family Doctor Name         Doctor Phone #

___________________________________________________________________
Doctor Address

___________________________________________________________________
Insurance Company  & Policy #

Medical Questionnaire:

Is your child presently being treated for an injury or sickness or 
taking any form of medication for any reason?

___________________________________________________________________

Is your child allergic to any type of medication?

___________________________________________________________________

Does your child require a special diet?

___________________________________________________________________

Does your child have (or ever had) any of the following?  (Please circle)

(Seizure Disorders)  (Asthma)  (Heart Murmur)  (Diabetes)  (Hay Fever)  

(Kidney Disease) 

Does your child have any allergies (other than to medications)?

___________________________________________________________________

Does your child sleep walk?  ______________________________________

Does your child get nervous or upset easily?  _____________________

Does your child have any physical handicap or illness which would 
prevent him/her from participating in normal rigorous activity?

___________________________________________________________________

NOTE:  If you answered yes to any of the above questions, please answer 
as completely as possible.  You may use the back of this sheet if necessary.

Can your child swim?  _____________________________________________

Medical Treatment Authorization:

I understand that I will be notified in the case of a medical emergency. 
However, in the event that I cannot be reached, I authorize the calling of 
a doctor and the providing of necessary medical services in the event my child 
is injured or becomes ill. I understand that Penn Grove Retreat will not be 
responsible for medical expences incurred, but that such expenses will be my 
responsibility as parent and/or guardian.

I agree to notify the camp in the event of any health changes which would 
restrict my child's participation in any normal youth activity.  I also 
understant that the aduld supervisors reserve the right to restrict my child 
from any activity that they do not feel is within the physical capabilities 
of my child.

_______________________________        ____________________________
Signature of Parent/Guardian           Date