Sarah Pirtle and the Discovery Center

Medical Form (2022)

After your Journey Camp registration is confirmed, please fill out and submit the online medical form below, or print out the printable medical form and return it signed by a parent. This form lets us know how to reach you during camp and describes health needs. A parent’s signature is what’s needed: state regulations don’t require for it to be signed by a physician. As long as your child has had a physical in the last two years, a new physical isn’t required for camp.

    Emergency & Medical Information

    Child's Information

    Name of Child:
    Age:
    Date of Birth:
    Home Address:

    Emergency Information

    Give helpful details about the times people can be reached at these numbers:

    FIRST PERSON to contact in case of emergency (​easiest person to reach​):
    Name of Parent/Guardian:
    Home:
    Work:
    Cell:

    SECOND PERSON to contact in case of emergency (​easiest person to reach​):
    Name of Parent/Guardian:
    Home:
    Work:
    Cell:

    THIRD PERSON to contact in case of emergency (​easiest person to reach​):
    Name of Parent/Guardian:
    Home:
    Work:
    Cell:

    PLEASE SIGN:

    I authorize emergency medical care for my child named:

    Parent signature of agreement:

    Family Physician/Health Care Provider

    Name of Family Physician or Health Care Provider:

    IMPORTANT: Phone Number of Family Physician or Health Care Provider:

    HEALTH PLAN/ INSURANCE COVERAGE​:

    Medical Information

    This section must be signed below by parent!

    DATE OF PHYSICAL EXAM conducted during preceding 24 months:

    Allergies?

    Any injuries, medical conditions or restrictions?

    Other relevant health history?

    Required medications?

    PLEASE NOTE: ​In order to administer at camp any medication from home, we will need written authorization from you and clear written instructions. Mail us a letter​.

    COVID-19

    All relevant information related to COVID that might include prevention measures, vaccination, family health.

    Has she had any hospitalization this year or need for medical care? Please describe.

    If family members have been hospitalized this year, please describe.

    IMMUNIZATION RECORD: (please list dates)
    Poliomyelitis:
    Tetanus:
    Measles:
    Diptheria:
    Mumps:
    Pertussis:
    Rubella:

    IMPORTANT: SIGNATURE of parent: