Massachusetts- Health & Release Form LinkedInThis field is for validation purposes and should be left unchanged.Camp DatesCamper/Staff Name 1WeightHeightAgeSexCamper/Staff Name 2Home TelCamper/Staff SignatureIf under 18 years of age, Parent/Guardian SignatureTel WTel HNameTelThe camp health staff may administer the following over-the-counter medications: Advil/Generic Tylenol/Generic Neither The camper or staff member may self-administer the following: Epi-pen Inhaler Neither Health Care CarrierPolicy NumberPolicy HolderHolders DOBSignature of Parent/GuardianDate SignedAllergies Yes No Explain 1Special Diet Yes No Explain 2Explain 2Special Needs Yes No ExplainPrescription Meds Yes No Explain 1Camper is not able to participate in all camp activities Yes No If Is not please explain restrictionsProviders NameLicense and StateProviders AddressEmergency Contact Telephone NumbersEmergency Contact Telephone Number 2MedicationExpiration DateIndividual DosageTimes GivenComments, Directions, Special Instructions:Parent/Guardian SignatureDate Signed_2
