KINGSTON TOWNSHIP SUMMER RECREATION PROGRAM 2009 MEDICAL HISTORY FORM
CHILD’S NAME: DATE OF BIRTH:
MEDICAL HISTORY:
Family Doctor:
Phone #
Present Medical History: (Please list all medications)
Allergies: (Please list, if any)
Past Medical History:
Hospital Preference:
continued
Page 2 EMERGENCY CONTACTS: 1st Name Phone (Home) Cell 2nd Name Phone (Home) Cell 3rd Name Phone (Home) Cell Phone (work) Pager Phone (work) Pager Phone (work) Pager
Please list the names and phone # of authorized person (s) OTHER THAN YOURSELF who may pick up child/children: 1. (name) 2. (name) 3. (name) Phone # Phone # Phone #
Please check the box that best describes the level of your child’s swimming ability and add any comments that would help the counselors provide the appropriate supervision for your child: Beginner Comments: Intermediate Advanced
Signature Parent (s) or Guardian (s)