CAMPBELLS KIDS CLUB

PG. 4

MEDICAL RELEASE FORM

Childs Name: _________________________________________ Date of Birth: _____________________

Address: _____________________________________Home Phone: (______) - _____________________
Physician: _____________________________________ Phone: (_______) - ___________________
Address: _______________________________________________________________________________
Street
Town / City
State
Zip
Dentist: _______________________________________Phone: (_______) - ____________________
Orthodontist: __________________________________Phone: (_______) - _____________________
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Parent / Guardian with Legal Custody to be contacted in case of illness or injury:
Name:
Preferred Phones: Home: (

Relationship to Child:
)

Cell: (

Work: (

Email:_________________________________________________________________________________
Home Address:__________________________________________________________________________
(If different from above)
Second Parent / Guardian or Other Emergency Contact:
Name:
Relationship to Child:
_______________________________________________________________________________________
Preferred Phones: Home: (
)
Cell: (
)
Work: (
)
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Hospital: _______________________________________________________________________________
Insurance Carrier: __________________________________ Policy #:______________________________
List any current allergies: __________________________________________________________________
_______________________________________________________________________________________
Food reactions / restrictions: _______________________________________________________________
_______________________________________________________________________________________
General Health History:
YES or NO
Has / does the child:
1. Ever been hospitalized?
2. Ever had surgery?
3. Have recurrent / chronic illnesses?
4. Had a recent infectious disease?

5. Had a recent injury?

6. Had asthma / wheezing / shortness of breath?
7. Had seizures?
8. Traveled outside the country in the past 9 months?
9. Had fainting or dizziness?
10. Passed out / chest pain during exercise?
11. Had Mononucleosis (Mono) during the past 12 months/
12. Ever had back / joint problems?
13. Have any skin problems?
14. Have diabetes?
15. Had headaches?
16. Wear glassed, contacts, or protective eyewear?
Please explain Yes answers in the space below, noting the number of the questions. For travel outside the
country, please name countries visited and dates of travel.

Mental, Emotional, and Social Health:

YES or NO
Has the child:
1. Ever been treated for attention deficit disorder (ADD) or attention deficit / hyperactivity disorder
(AD/HD)?
2. Ever been treated for emotional or behavioral difficulties or an eating disorder?
3. During the past 12 months, seen a professional to address mental / emotional health concerns?
4. Had a significant life event that continues to affect the childs life?
History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster,
others,
Please explain Yes answers in the space below, noting the number of the questions. Campbells Kids Club
may contact you for additional information.

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WHAT HAVE WE FORGOTTEN TO ASK? Please provide in the space below any additional
information about the childs health that you think important or that may affect the childs ability to
fully participate in the program.

Medications being taken (prescription and over the counter):

_______________________________________________________________________________________
_______________________________________________________________________________________
Reasons for medications: __________________________________________________________________
_______________________________________________________________________________________
The School Age Child Care Program does not dispense medication without written documentation from a
doctor and the approval of the Director. Please complete the Permission to Give Medication Form.
Please share any special physical, educational (including IEP or 504) or emotional concerns or past medical
treatments so that we can ensure our staff provide a suitable environment for your child.
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Medical Insurance Information:
This child is covered by family medical / hospital Insurance _______Yes _______ No
Include a copy of your Insurance Card if appropriate: copy both sides of the card so information is readable.
Insurance Company: _____________________________________Policy Number: ___________________
Subscriber: ___________________________________Insurance Company Phone #: (

) _____________

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Parents Authorization:
The health history is correct as far as I know, and the child herein described has vaccination records on file
with the Board of Education, is in good health and haws permission to engage in all the normal activities of
the Before / After Care Program.
In the event that I cannot be reached in an EMERGENCY, I hereby give permission to the medical
personnel selected by the Director to transport, hospitalize, and secure proper treatment, order x-rays,
injection, anesthesia or surgery and to release any records necessary for insurance purposed for my child as
named above.
_________________________________________________
Signature of Custodial Parent / Guardian

___________________________
Date

Relationship to Child: ____________________________________________________________________