CGI - Health Form - Chabad Lubavitch of Wyoming

THIS FORM TO BE COMPLETED BY PARENT OR GUARDIAN

Child's Name*

First Name Last Name

Date of Birth*

Month Day Year

Gender*

MaleFemale

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone *

Father's Name*

First Name Last Name

Home Phone

Business Phone

Mobile Phone*

E-mail*

Address (if different from above)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's Name*

First Name Last Name

Home Phone

Business Phone

Mobile Phone *

E-mail*

Address (if different from above)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact 1*

First Name Last Name

Home Phone 1*

Cell Phone 1*

Relationship 1*

Emergency Contact 2

First Name Last Name

Home Phone 2

Cell Phone 2

Relationship 2

Does your child take medication regularly?*

YesNo

If yes, what kind?

Permission to give Tylenol or Benadryl if needed?*

YesNo

Does your child have allergies?*

YesNo

If yes, please specify:

Existing medical conditions or injuries:

Special needs/diets:

Does your child have any social or emotional problems or any medical condition of which we should be aware of in caring for him/her?*

YesNo

Please explain:

Family Doctor

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

This health history is correct as far as I know & the person herein described has permission to engage in all prescribed camp activities except where noted.

Authorization for Treatment: I hereby give permission to the medical personnel selected by the Director to order X-rays, routine tests, treatment & necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Director to secure & administer treatment, including hospitalization for my child as names above.

*

I agree with the statements above

Name of Parent or Guardian*

First Name Last Name

Relationship*

Date*

Month Day Year

CGI - Health Form

Father's Information

Mother's Information

Emergency Contact Details

Child Health Information

Family Doctor's Information

Authorization

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