Tennis Camp 2012
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Personal Information
Last Name:
First Name:
Email:
Sex:
M
F
Age:
Date of birth: (yyyy/mm/dd):
Year:
Month:
Day:
Registered in week(s) #:
Medicare No.:
Exp. date:
Medical Background
1. Have you had a medical exam in the past year?
No
Yes
2. Do you suffer from any of the following: diabetes, recurrent headaches, fainting, epilepsy, high blood pressure, abdominal pain, asthma, dizzy spells?
No
Yes
If Yes, please state which condition, along with details:
3. Do you suffer from allergies?
No
Yes
Specify:
4. Do you wear a medical alert bracelet?
No
Yes
Specify:
5. Are you taking any medication, while at camp?
No
Yes
Specify:
6. Have you been hospitalized within the last year?
No
Yes
Specify:
7. Do you suffer from any physical problems or injuries?
No
Yes
Specify:
8. Do you wear contact lenses?
No
Yes
In case of an emergency, who should we notify?
Last Name:
First Name:
Tel:
Tel (work):
