Milton Parks and Recreation
525 Canton Avenue
Milton, MA 02186
617-898-4940, 617-696-1026(FAX)
MEDICAL INFORMATION
2011 SUMMER PLAYGROUND PROGRAM
CAMPERS AND STAFF UNDER AGE 18
Name: __________________________________________________________
Date of Last Physical Exam: _______________________________________
SIGNIFICANT MEDICAL HISTORY - List Dates ___________________ ____________________________________________________________________
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ALLERGIES:________________________________________________________
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MEDICATIONS: ____________________________________________________
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PLEASE LIST ANY HEALTH CONDITIONS OR IMPAIRMENTS WHICH MAY AFFECT ACTIVITIES WHILE ATTENDING CAMP:
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Parent/Guardian Signature Date
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