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Child's Name*
First Last
Child's DOB*
MM slash DD slash YYYY
Caregiver Phone Number*
Caregiver Email*
Location Seen*
Delivery Method*
Fax Number
Address*
Street Address Address Line 2 City State ZIP Code
Upload Document*
Max. file size: 300 MB.
Upload Document
Max. file size: 300 MB.
Upload Document
Max. file size: 300 MB.
Is this form for overnight camp?*
- Yes
- No
Will your child be taking medications at camp?*
- Yes
- No
Does your child or either parent have Sickle Cell Trait?*
- Yes
- No
Since Your Child’s Last Checkup:
Any injury or illness?*
- Yes
- No
Chronic illnesses, hospitalizations, or surgeries?*
- Yes
- No
New medications or supplements of any type?*
- Yes
- No
Allergies to medications, insects or food?*
- Yes
- No
Dizziness, passed out, experienced chest pain with exercise, or sudden death in a close relative < 50 years old?*
- Yes
- No
History of hypertension or murmur?*
- Yes
- No
Concussion, “knocked out”, unconsciousness or memory loss, seizure or severe/frequent headache?*
- Yes
- No
Asthma, allergies, wheezing, difficulty breathing, chest pain?*
- Yes
- No
Strain, sprain, fracture, joint pain or swelling?*
- Yes
- No
Please explain any “yes” responses here:
Please allow 7 – 10 business days for processing. Complete the parent/caregiver section of the form(s) before downloading. Failure to do so will result in a delay. There is a $10 fee for each form, $15 for FMLA. Payment is due before the form is completed. Click Here to complete your form payment, or you can pay at the time of pick-up in our office.

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Medical Library

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Bala Cynwyd

33 Rock Hill Rd
Suite 170
Bala Cynwyd, PA 19004
Call: (610) 257-9000
Fax: (484) 270-8133

Center City

1740 South Street
Suite 200
Philadelphia, PA 19146
Call: (215) 735-5600
Fax: (215) 735-5690

Fishtown

2365 East York Street
Philadelphia, Pennsylvania 19125
Call: (215) 278-2500
Fax: (215) 644-9083

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