Medical FORM | MelodyFairchild

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Athlete's Name*
FirstLast
Email
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History of lacerations, injuries or illnesses:
Allergies (food, animals etc.)
Activity Restrictions
Special Medications taken outside of camp & REASON
Be sure to let me know why you take this medication.
Medications to be taken at camp & REASON
NOTE: Medication must be in original containers and accompanied by Medication Administration Forms signed by you and your doctor indicating them and dosage. All medication must be kept at the office.
Most of our activities will take place in an outdoor environment. At this altitude the sun is stronger. Don't forget your hat and sunscreen.
Any other helpful information
Family Doctor
DR. Phone
Name of Insurance Carrier* Note: A photocopy of Camper's Insurance card must be brought to Camp
Insurance Member Name
Group #
Group #
Please Mail Photocopy of Your Insurance Card
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Most of our activities will take place in an outdoor environment. At this altitude the sun is stronger. Don't forget your hat and sunscreen.