2011 medical form (2011medicalform pdf)

Please complete the first 2 pages and return them to us within 10 days.
If you have any questions, please call Pat Sears @ (413) 746-2523 or N e w S p i r i t W e e k
Send an e-mail to: [email protected]. Mail completed form to: NSW 2011 40 Riverview Terrace Springfield, MA 01108-1629
Camper Information
Camper’s Full Name: __________________________________________ Preferred nickname: ______________________ Home Phone #: ( ) ____________________________ Cell Phone #: ( ) ____________________________ Home Address: ____________________________________________________________________________________________ City, State & Zip: ________________________________________________________________________________________ Mailing Address (if different): _________________________________________________________________________________ Camper’s E-Mail Address (please print very clearly): _______________________________________________________________ Camper’s IM Screen Name (if different): ________________________________________________________________________ Social Security Number: _________________________________________ Date of Birth: __________________________ Grade completed in June 2011: _______ Parish (include city please): _____________________________________________ Which school will you be attending next year? _________________________________________________________________ Roommate preferences? 1st) ______________________ 2nd) ______________________ 3rd) _______________________ T-Shirt Size (based on adult sizes): please circle your preference We traditionally put together a list for the campers of everyone’s name, address, phone number, date of birth, and e-mail address. If you have anyobjection to your information being included on the list, please complete the following section: DO NOT include the following: ___ address ___ phone number ___ cell number ___ e-mail address ___ IM screen name
I, (parent/guardian) of __________________________, hereby give permission to the RN’s serving as nurses at New SpiritWeek 2011 to administer to my child the following medications, if the Camp Nurse deems it necessary. Dosages will beadministered according to directions on the bottle, unless a physician directs otherwise.
Parent/Guardian Signature: _____________________________________________ sunburn, sprain, fever, headache, menstrual cramp Allergies: _________________________________________________________________________________________________ Health History (asthma, diabetes, etc.): _______________________________________________________________________ __________________________________________________________________________________________________________ Daily Medications: _________________________________________________________________________________________ ___________________________________________________________________________________________________________ Please note: all medications should be in original container, labeled by pharmacy, with:
camper’s name, name of medication, dosage of medication, physician’s name, and expiration date.
Parent & Emergency Information (to be completed by a parent or guardian)
Mother’s Name: _____________________________________________ Phone (h): ________________________________ Home Address: ______________________________________________ Phone (w): ________________________________ City, State & Zip: ____________________________________________ Phone (cell): ______________________________ Mailing Address (if different): _______________________________________ Occupation: ______________________________ Mother’s E-Mail Address: _____________________________________ E-mail Address = ___ at home or ___ at work Father’s Name: _____________________________________________ Phone (h): ________________________________ Home Address: ______________________________________________ Phone (w): ________________________________ City, State & Zip: ____________________________________________ Phone (cell): ______________________________ Mailing Address (if different): _______________________________________ Occupation: ______________________________ Father’s E-Mail Address: _____________________________________ E-mail Address = ___ at home or ___ at work In the event of an emergency, if we are unable to reach either parent, who should we contact?
Emergency Contact’s Name: __________________________________ Phone (h): ________________________________ Address: ___________________________________________________ Phone (w): ________________________________ Relationship with Camper: ___________________________________ Phone (cell): ______________________________ Camper’s Primary Care Physician: ___________________________________________________________________________ Physician’s Address: _______________________________________________________________________________________ City, State & Zip: ________________________________________________________________________________________ Phone #: ( ) __________________________________ Insurance Company: _______________________________________ Policy #: _________________________________ Group #: ______________________________ Name of Employer or Union: ____________________________________ Policy Holder’s Name: ______________________________________________________________________________________ All campers must sign this release
In consideration or New Spirit, Inc. accepting my registration for New Spirit Week 2011 (August, 2011) at Holy Cross Campgrounds, on behalf of
myself, my heirs, assigns, executors and personal representative, I release, hold harmless and discharge forever the New Spirit staff, it’s officers, di-
rectors, employees, agents, sponsors, promoters, and affiliates from any and all liability, claim, loss, damage, cost or expense, and waive such claims
against any such person or organization arising directly or indirectly from or attributable in any legal way to any action or omission to act of any
such person or organization in connection with the sponsorship, organization and execution of New Spirit Week 2011. I understand that video
and/or photographs of campers may be used for promotional purposes.
Signature of camper: ___________________________________________________ Campers under 18 must have a parent or guardian sign this release
As parent or guardian of the camper, I give my permission for my child or ward to register and attend New Spirit Week 2011 (August, 2011) and
further, in consideration of the acceptance by New Spirit, Inc. of such registration, I agree individually, and on behalf of my child or ward, to the
terms of the above Release signed by the camper. In addition, I consent to medical treatment for my child for emergency purposes. I understand that
video and/or photographs of campers may be used for promotional purposes.
Parent/Guardian Signature: _____________________________________________ Please mail this form (with a copy of the camper’s immunization record) to:
NSW 2011 40 Riverview Terrace Springfield, MA 01108-1629. We would
appreciate you returning this form to us: within 10 days. Thank you.
N e w S p i r i t W e e k
We ask that this form be completed based on a physical exam which has taken placebetween January 1st, 2010 and July, 2011. If that is not possible, please contact us. Please have camper’s Primary Care Physician fill out this form. Thanks.
This is to certify that ________________________________ had a personal health appraisal on _________________.
This included: _____ Appropriate lab tests, if indicated.
This certificate of health denotes that the above named person was found to be in good health and free of communicabledisease.
Enclosed is a copy of their immunization record. _____ Yes _____ No Physician’s Signature: ____________________________________________________

Source: http://www.newspiritinc.org/nsi/nsw/2011medicalform.pdf