St. John's Episcopal School: Serving Preschool - 8th Grade

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St John's Episcopal School

St. John's Summer Camp Medical Form

Name:

Does participant attend a school in the State of Maryland?

If no, a copy of your child's immunization record must be on file before start of program.

Date of last Tetanus shot: (DTP or DT, do NOT leave blank)

Health Insurance:

Policy Number:

Physician:

Phone Number:

Dentist:

Phone Number:

Medical Condition:

Allergies:

Medications:

Glasses/Contacts:

EMERGENCY CONTACTS
(persons to call if parent/guardian cannot be reached)

Name:

Relationship:

Phone:

Cell:

Name:

Relationship:

Phone:

Cell: