Medical History Form

Participant Name: Camp Dates (eg. 01/02/05) : to

Allergies:	Specify:
Hay Fever
Asthma
Poison Ivy/Oak
Insect Stings
Food
Other

Medication (specify):

Briefly describe allergy symptoms:

Please list below any prescribed medication/dosage:

Medical Restrictions:

Emergency Contact: Relationship: Phone Number: ( )

I hereby authorize and request Pamplin Historical Park to secure necessary emergency care and treatment for me or my child
(if applicable) should the need arise.

Our family physician is: Phone Number: ( )

My child is physically able to participate in all program activities. If he/she appears to be ill, I will not send him/her to the program. I have listed any restrictions, allergies, or medications to be taken on this form.

Signature of Participant or Parent/Legal Guardian:___________________________________________ Date:__________
(Required if participant is under the age of 18.)

Print this form, and FAX or mail it to us at:

The Civil War Adventure Camp,
Pamplin Historical Park
6125 Boydton Plank Road
Petersburg, VA 23803
( 804) 861-2820

Electronic submission coming soon!