Health History – University of Maryland Softball Camps

YOUTH CAMP HEALTH HISTORY CAMPER

Camper’s First Name * :

Camper’s Last Name * :

Camper Date of birth

Street address

City

State

Zip Code

Camper email address

Parent Contact Information

First Name * :

Last Name * :

E-Mail

Phone Number

Street address

City

State

Zip Code

Alternate Parent

Not Applicable

First Name

Alternate Parent Last Name

Alternate Mobile Phone Number

Alternate Email Address

PHYSICIAN CONTACT INFORMATION

First Name:

Last Name:

Phone * :

Physician’s Medical Practice Name* :

Phone * :

HEALTH INFORMATION:

Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?

Yes

Explain *

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?

Yes

Explain *

IMMUNIZATION INFORMATION:

Must list current residence above.

For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?

Yes

List *

For campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896.

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