Medical History

Medical History

Name of Child	Date(s) of History Camp participation

Allergies:	Specify:
Hay Fever
Asthma
Food
Insect Stings
Medication
Poison Ivy/Oak
Other
Briefly describe allergy symptoms:

Please list below any prescribed medication currently taken by your child:

Will your child need to take medication while he/she is in the park? Yes No
Medical Restrictions (Give details):

Medical or dietary regimen to be followed (please attach specific information if necessary) :

I hereby authorized and request Pamplin Historical Park to secure necessary emergency care and treatment for my child should the need arise.
Our family physician is:_________________________________________________________________
Doctor's name or name of practice & telephone 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.
Person to be notified if parent/guardian cannot be reached:

Name	Relationship	Phone:

Signature of Parent or Guardian:_________________________________________________________
Date:________________

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

Pamplin Historical Park
6125 Boydton Plank Road
Petersburg, VA 23803
( 804) 861-2820

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