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Medical/Emergency Form


This form must be on file in order to participate in Summer at Siena activities.  If you have any questions, please contact info@thesienaschool.org
 
Camper's Name
MEDICAL PROVIDER & INSURANCE INFORMATION
Camper's Physician's Name
Physician Phone
Physician Address
Medical Insurance
Policy Number
Group Number
Policy Holder Name
Policy Holder's Relationship to Insured Camper
GENERAL CAMPER HEALTH INFORMATION
Health Problems (including physical, psychiatric, or behavioral problems which we need to be aware of?)
NO
YES
If yes, please explain
Allergies, dietary restrictions or special needs which we need to be aware of?
NO
YES
If yes, please explain
Camper Wears (contacts/glasses, hearing aid, etc.)
NO
YES
If yes, please explain
Medications the camper is currently taking (including over-the-counter medications)
NO
YES
If yes, please explain
IMMUNIZATION INFORMATION
For campers who reside within the United States, a United States territory, or the District of Columbia:
1. State/territory in which child resides:
2. Is this child exempt from any Immunizations?
NO
YES
If yes, please explain
OR
For campers who reside outside the United States, a United States territory, or the District of Columbia:
1. Country in which child resides:
2. Attach Department form DHMH-896 (record of vaccination or immunity)

File Upload:
I certify the above information is correct and will notify Siena officials should any information change. I authorize Siena officials to administer first aid and/or take my child to a physician or hospital for emergency treatment, and/or activate the Emergency Medical System (EMS) in the event it appears necessary and a Parent (Guardian) cannot be contacted.
Name of Parent/Guardian
Electronic Signature of Parent/Guardian
Yes
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