Physician's Medical Statement by myi16408


									              PHYSICIAN MEDICAL STATEMENT
              Please return this form BEFORE MAY 1st to:
                       The Oxbow School
                       530 Third Street
                       Napa, CA 94559
              If you have any questions, you can contact us at: 707-255-6000

              PHYSICIANS: The camper listed below is registered to attend Oxbow Summer Art Camp.
              While doing art is the primary activity he/she will be engaged in, we also offer time for
              field sports, kayaking, swimming and, of course, the occasional water fight.

              Campers Name___________________________________             Session ____________________

              Camper’s Birth Date___________________         Gender ______________      Age ____________

              Are there any restrictions to this camper’s activities or precautions which should be taken with this

              camper? _______________________________________________________________________________


              Is the camper currently under the care of a physician for a specific condition? If so what? Is the treat-

              ment to be continued at camp? _______________________________________________________


              Does the applicant have epilepsy? __________       Does the applicant have diabetes? ____________

              Does the camper have any allergies, (food, medical, insects, & other)?_________________________

              Are there any other health-related issues we should know about regarding this camper?


Physician’s   Is there any other information, medical or other, which would assist us in providing this child a healthi-

 Medical      er, happier, more productive or safer summer? ________________________________________

Statement     _______________________________________________________________________________________


              Physician's signature: ___________________________________________ Date: _________________

              Physician’s phone number:__________________        Fax number: ________________________________

              Pager/cell number: ________________________         Emergency number: _________________________

              Physician’s address: _____________________________________________________________________

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