(영문) 캠프건강 기록서(Camp Health Form)

camp health form
to be completed by camper s parent / guardian
completed health form must be mailed to the camp office by july 00 th.
medications will be collected when camper arrives at camp and kept in the health centre.
name:
last first
date of birth: height: weight:
mm/dd/year
canadian residents, please provide your provincial health card number (and a photocopy of the card) and ensure that information is
complete and accurate.
province: health card #:
version code:
non-canadian residents, please list any medical plans and numbers.
plan and number:
names of parents: /
father mother
home address: city:
province/state: postal code/zip:
home phone: ( )
cell phone: ( ) ( )
summer phone: ( )
father mother business phone: ( ) ( )
father mother in case of illness (when parents are unable to be reached) please notify:
telephone: ( ) relation:
if the camper has, or has had, any of the following, please check:
chicken pox sinus trouble stomach aches diabetes asthma
measles frequent colds hernia whooping cough impetigo
heart murmur rheumatic fever discharging ear hay fever bed wetting
appendicitis sleepwalking t mumps
any allergies? describe:
(이하 생략)