APPENDIX C
PO Box 380, Westhampton, New York 11977
(631) 288-4658
PHYSICAL EXAM FORM
To be completed and approved by the student's primary care provider/physician.
Dear Health Care Provider:
Your cooperation in supplying the following information about an applicant for RAYNOR COUNTRY DAY SCHOOL is greatly appreciated. The child will not be accepted without your approval on this form.
To Parent/Guardian: Please complete boxed information BEFORE submitting to Physician.
Name of applicant___________________________ Gender (circle one) M F
Date of Birth _______/_________ Address:____________________________________
Date of most recent exam:
I have read the Medical Management Plan, attached to this form, and certify that it provides an easy to understand, complete regime of care for this child's safety at camp. I recognize that the student will be active at this camp and represent that this plan accounts for applicable varying activity levels.
Have any complications of health or disabilities been detected? Yes/No (circle one)
If yes, please specify:
Is the student emotionally and physically mature or responsible enough to independently manage his/her health concerns? Yes______; No_____.
If not, please explain the minimum level of medical licensure and training required for the student's safety (unless fully described in the Medical Management Plan):
Do you have any specific concerns regarding the management of this child's health or health at school not fully described in the Medical Management Plan? Yes____, No____.
If yes, please explain:
Do you recommend any limitation on Student's activity while at camp beyond those described in the Medical Management Plan? Yes _______ No ______ If yes, please describe:
I certify that the information above is correct to the best of my knowledge and agree to answer questions and provide management guidance to the camp at Raynor Country Day School as requested by the school at the sole cost and expense of the parent/legal guardian of the student.
Primary Care Physician's Name (typed or printed)
_____________________________________________________________
Address: _____________________________________________________
Phone: (____)__________
Primary Care Physician's Signature:
_________________________________________________
Parents/Guardians name (typed or printed)
_________________________________________________
Address: _______________________________________________________________
Phone: (____)_________________
Parents/Guardian Signature:
Father: ____________________________
Mother: ____________________________
Legal Guardian: ____________________________