You can complete
the form by:

  1. Submitting the online form
  2. Download/Print/Fax the form below
MedicalForm12.pdf
File Size: 71 kb
File Type: pdf
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This form must be completed for EACH CHILD and submitted prior to June 1st, 2012.  It DOES NOT need to be filled out by a physician, BUT if the camper is 6 years of age or less, Dade County requires that you provide us a physician-signed copy of a current (within 12 months of 5/29/12) HRS Form 3040 (Cert of Good Health) and HRS Form 680 (Cert. of Immunization).

    Health and Emergency Contact For Campers

    IMMUNIZATION RECORDS - Please provide approximate dates (MM/DD/YY) for each.
    MEDICAL INFORMATION - Type "NA" if no conditions present for each.
    RELEASE: This statement must be agreed to in order for your child to attend camp:

    "This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities as noted.  AUTHORIZATION FOR TREATMENT: I hereby give my permission to the medical personnel selected by the camp director to: order X-rays, treatments, and release of any records necessary for insurance purposes, and to provide or arrange any transportation for my child (camper) in the event I cannot be reached in an emergency.  I hereby give my permission to the physician selected by the camp director to secure and administer treatment including hospitalization for the above named child (camper).
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