Horse Day Camp Health Verification
This form must be filled out by a licensed physician ONLY if your child has any impairments or limitations which would impair his/her ability to perofrm lessons specified on this day camp. A standard physician’s school camp health form
may be used in place of this form. Each Camper must have a physical within 18 months prior
to attendance at the Darcy Edwards Training Center.
Camper’s Name:
Last _______________________
First ___________________		 [ ] Male
Birth date ______________
[ ] Female

Was examined and found to be in good health and immunizations are current.
In my opinion, the above applicant [ ] is able [ ] is not able to participate in an active horse camp program.

Date of last Tetanus booster: ____________

Description of any restrictions or limitations:

 

The applicant is under the care of a physician for the following conditions:

 

Current treatment at time of this report includes:

 

Treatment to be continued at camp:

 

Medications (name, dosage, frequency):

 

Identify any medications taken during the school year that applicant does/does not take during the summer:

 

Any additional information that you as the examining physician feel would be beneficial for the camp to know about this patient:

 

Examining Physician Signature(s):

 

Physician name (printed):

 

Address:

 

Telephone number: