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Medical Information Form

A Doctor's visit is not required to complete this form. You can:
1. Fill it out yourself (fill it out online, then print & sign), and attach a copy of the immunization record;
2. Print out this form and forward to your Doctor to fill out then return to us; or
3. Send us your Doctor's own form including the immunization record
Camper's Name:
Sex: Male   Female
Food Allergies:
Drug Allergies:
Allergic conditions:
Date of Birth:
Parent's Name:
Immunizations(Please give dates)
DPT:
Sabin Polio:
Measles:
Mumps:
Rubella:
Hepatitis B:
Varivax:
MMR:
HIB:
Tuberculin Test:(within 12 months)
Hayfever:
Asthma:

Is there any physical, emotional or health problem of which the camp should be informed?
 
Is the camper currently under medical treatment? If yes, please specify:
 
Please give any information you may have that may be of use to the camp:
 
Physician's Signature:
Address:
Telephone:
Date of Physical Examination:

The Art Farm • P.O. Box 1976 • Bridgehampton, NY 11932
Phone 631.537.1634 • Fax 631.537.2295  Email: [email protected]

Tuition  :   Bus Transportation Form  :  Registration Form   :   The Art Farm in the Hamptons home page