Medical Examination Form printable pdf download

2015-2016

Easter Seals Wisconsin Camps

Page 1 of 2

Medical Examination Form

To be completed by Licensed Medical Personnel

(Physician, Physician Assistant or Nurse Practitioner)

Please list the applicant’s primary physician if different from the licensed medical personnel filling out the form. The

person named below has been accepted to camp and

has permission to engage in all camp activities except as

noted below. Easter Seals Wisconsin Camps has been given permission to provide routine health care under the

guidance of the camp’s medical director, administer prescribed medications, and seek emergency medical treatment

including ordering x-rays or routine tests by the Camper/Guardian signing the releases section of the camp

application. The person named below has also agreed to release any records necessary for treatment, referral,

billing, or insurance purposes.

By the camper/guardian signing the releases section on the camp application, Easter Seals Wisconsin Camps has

been given permission to arrange necessary related transportation for the person named below. If the guardian/

parent cannot be reached in an emergency, they hereby gave permission to the physician selected by the camp to

secure and administer treatment, including hospitalization, by signing the releases section of the camp application.

Camper Name: _________________________________________________________Date of Birth ____________

Camper Address: ______________________________________________________________________________

Camper Home Phone: _________________________________ Cell Phone: _______________________________

Primary Physician: ________________________________________________Phone #: (_____)_______________

I examined this individual on ___/____/_____. Easter Seals Wisconsin requires annual exams. A new exam is not

necessary if you have a copy of a current and comparable physical form used for another camp/program.

BP:__________________ Pulse: ____________________Weight: _________________Height:________________

Free of Communicable Disease as of _______________________

Record of immunizations (if obtainable) and date of last tetanus shot:______________________________________

_____________________________________________________________________________________________

Description of any camp activity restrictions: _________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________

Medical Examination Form