EmailMe Form - WBW Student Medical Information Update

Today's Date

MM / DD / YYYY

Please Note: This form uses ReCaptcha (TM) technology to keep your information safe and strictly confidential.

Summer/Acceptance Email Address: *

Please confirm the registration email address that will be checked regularly and will not be changed until after August 2015.

Program Location *

Student Name *

First Last

Date of Birth *

MM / DD / YYYY

MEDICAL INFORMATION UPDATES

If you have any questions about a specific medical situation or questions or concerns about taking medications at camp, please do not hesitate to call or email us.

1. MEDICATIONS

Are you bringing any new or additional medications to camp? *

Yes

No

What medications and what is their purpose?

Please note: Students will self-administer medications. Our medication policy can be found online at http://www.wbw.org/reader.aspx?pg=Student_Medication_Policy.htm.

Are any of these medications controlled substances?

Yes

No

2. PHYSICAL ACTIVITY

Are you currently limited in any physical activity? *

Yes

No

Please describe your activity limitations.

3. MEDICAL HISTORY

Has anything changed in your medical history since you completed your Medical Form? *

Yes

No

Please describe the changes in your medical history.

SUBMIT FORM

By typing my name below, I am indicating that the information I have provided is true to the best of my knowledge.

Parent/Guardian Name *

Date *

MM / DD / YYYY