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Tempe Moore-Equestrian Director

5818 Butler Road

Gibsonville, NC. 27249

336-708-0692

Health Form


                                                                                                                                                                                                                            

              YONAHLOSSEE  SADDLE CLUB HEALTH FORM                                

                                                                                                                                                                            

Camper Name_________________________________________________

Age _____

Date _________

Parent’s phone number________________ Cell______________________                       

 Emergency contacts and numbers _________________________________

 _____________________________________________________________

Past history of serious lacerations, injuries or illnesses ________________

 _____________________________________________________________

Allergies  (include medicine, food, insects, plants)  ___________________

_____________________________________________________________

Does your child have asthma? _____________________  An inhaler?  ____     

 Penicillin or other drug reaction? _________________________________

Special medication or other reactions?  ____________________________

Any physical limitations? _______________________________________

_____________________________________________________________

Behavioral issues?________________________________________ 

 Hospital preference ___________________________________________

Doctor preference ______________________________________________

Food allergies or limitations? Favorite foods._________________________                                                    

                                                                                                                                                                             

I, ______________________ give the administrator and staff of Yonahlossee Saddle Club permission to act on behalf of my child if necessary in the case of a medical emergency. This could include administering first aid, or seeking further help from EMS, a local hospital or doctor’s office. Camp staff has my permission to administer __________________________________ medication to my child at

(time) _____________

                                                                                                                                                                             

Parent signature ______________________________________________