Civil War Adventure Camp Required Medical Waiver

Medical History Form

Participant Name:*

Participant Email:*

Camp Dates:*

Allergies:*
Hay FeverAsthmaPoison Ivy/OakInsect StingsFoodOther

Please Specify:*

Please Specify Medications:*

Briefly Describe Allergy Symptoms:*

Please List Any Prescribed Medication/Dosage:*

Medical Restrictions:*

Emergency Contact:*

Relationship:*

Phone Number:*

I hereby authorize and request Pamplin Historical Park to secure necessary emergency care and treatment for me or my child
(if applicable) should the need arise.
Yes, I Agree.No, I Do Not Agree.

Our Family Physician is:*

Phone Number:*

My child is physically able to participate in all program activities. If he/she appears to be ill, I will not send him/her to the program. I have listed any restrictions, allergies, or medications to be taken on this form.
Yes, I Agree.No, I Do Not Agree.