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Thaddeus Stevens College of Technology

Stevens Experience Summer Camp 

Health History & Application 

Student's Health History
Student Name: *
First Name
Middle
Last Name
Prefers to be called:
Date of Birth:*
Primary Care Physician
Phone Number
Hospital Affiliation:
Allergies (List all known allergies, describe reaction and management of the reaction):
Food Allergies:
Other Allergies:
Medication(s) Being Taken: Please list all medications (including non-prescription drugs) taken routinely that you will be providing to our program staff. Please bring enough medication to last one week. Please keep all medications, prescription, and non prescription, in the original packaging/bottle naming prescribing physician (if a prescription drug), name of medication, dosage, and frequency of administration.
Medication Dosages, times taken each day, and reason for taking:
Stevens Experience Summer Camp Application
Home Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Student Weight
Student Height
T-Shirt Size (Pick One) *
Summer Camp Preference *
Special Interests and Hobbies
Father's Name
First Name
Middle
Last Name
Father's Address (If Different From Above):
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Father's Phone Number
Mother's Name
First Name
Middle
Last Name
Mother's Address (If different from above)
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Mother's Phone Number
Emergency Contact Name *
First Name
Middle
Last Name
Relationship to Child*
Emergency Contact Phone Number*
Emergency Contact Name:
First Name
Middle
Last Name
Emergency Contact Relationship to Child
Emergency Contact Phone Number