Camper Health History/Immunization Record for New York Giants Youth Football Camps

Name __________________________________________________________Birth date ______________

First                                                                Middle                                                            Last

Home address __________________________________________________________________________

                                            Street                                                                                                   City                                                        State                                        Zip

Camp Location(s):_________________

Please note:  Staff members are not able to administer any medications to campers.  For self-administration of an Epi-pen or inhaler, please execute the attached permission form.

ALLERGIES List all known.                                Describe reaction and management of the reaction.

Medication allergies (list)

_________________________                      __________________________________________________

_________________________                      __________________________________________________

Food allergies (list)

_________________________                      __________________________________________________

_________________________                      __________________________________________________

Other allergies (list) - include insect stings, hay fever, asthma, animal dander, etc.

_________________________                      __________________________________________________

_________________________                      __________________________________________________

Please provide any additional relevant medical history: ______________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Parent/Guardian Authorizations: This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp activities.  I hereby give permission to the camp to provide routine health care and seek emergency medical treatment, if needed.  I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the camp to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied.

Signature of parent or guardian:  ___________________________________________________________

Printed Name ________________________________________________________ Date _____________