New Canaan Recreation Department
YOUTH CAMP HEALTH EXAM/RECORD FOR CAMPERS AND STAFF
Physical Exams Are Valid for 3 Years From Date of Last Examination

                                                   Please Return Completed Form to:    New Canaan Recreation Department

____CAMPER                                                                                        P.O. Box 852 New Canaan, CT 06840

____STAFF                                                                                             FAX:  203-594-3606

Name__________________________________Birthdate___/___/___  Home Phone_______________

Guardian____________________________ Address________________________________________

Camp:____Waveny Camp           ____Camp Kidsville          

Session(s):  ____1      ____2      ____3      ____4      ____5      ____6

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TO BE COMPLETED BY THE SPECIFIED MEDICAL PRACTITIONER:

 Date of Current Physical Exam_____/_____/_____

____May participate in all camp activities

____May participate except for:_____________________________________________________________________________________________________________________________________________________________

Medical information pertinent to routine care and emergencies:___________________________________________________________________________________________________________________________________________________

Is this individual taking prescription or over the counter medication(s)?  ____YES       ____NO       If yes, indicate medication(s):_______________________________________________________________________________________

Does the individual have allergies?   ____YES   ____NO      Explain:__________________________________________

 Is the individual on a special diet?   ____YES   ____NO     Explain:____________________________________________

 Does the individual have special needs?   ____YES   ____NO    Explain:________________________________________

This camper/staff is up-to-date on all the following routine childhood immunizations currently recommended by the AmericanAcademy of Pediatrics and National Advisory Committee on Immunization Practices:

	Yes	No		Yes	No
Measles			Hepatitis B
Mumps			Diphtheria
Rubella			Pertussis
Chickenpox			Polio
Tetanus

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Print name of medical provider:___________________________________________________
Medical care provider’s address:_________________________________________________________
Medical care provider’s:   City/Town________________________________________ST____Zip Code_______

_____________________________________                 ***Important, signature and date must be
Signature of Physician, APRN or PA                        current with the same year the child is attending camp

__________________
Date Formed Signed
__________________
Telephone Number