Please return completed Paperwork to: Make Promises Happen, #1 Twin Cedar Lane, Guthrie, OK 73044-7041

Immunization Records, if known: Date most recent Immunization Records, continued: Date most recent

DTP (Diphtheria, Tetanus and Pertussis) PCV13 (Pneumococcal Conjugate Vaccine)

DTaP (Diphtheria, Tetanus, acellular Pertussis) Varicella (Chickenpox)

OPV (Oral Polio Vaccine) HepA (Hepatitis A)

IPV (Inactivated Polio Vaccine) HPV (Human Papillomavirus)

MMR (Measles, Mumps, Rubella) MenACWY (Meningococcal – A, C, W and Y)

HiB (Haemophilus b Conjugate Vaccine) MenB (Meningococcal B)

HepB (Hepatitis B) Influenza

Rotavirus TET-TOX (Tetanus Toxoid)

Has Camper had a TB Mantoux Test (tuberculin skin test)? ____________ Date of most recent: __________________ Result? _________________________

Please explain if Camper had a positive TB test: ______________________________________________________________________________________________________________

STOP - THIS SECTION MUST BE FILLED OUT BY YOUR PHYSICIAN

Physicals conducted for school, sports, or yearly exams will be accepted in lieu of the one below, provided they are

dated within the one (1) year span of camp attendance; must be kept current to attend camp.

feet & inches Systolic/Diastolic pounds

Medical Exam Information - to be completed by a health care provider & dated within the year of camp(s) to be attended

Blood Pressure: _______/______ Weight (imperial measure) ______________ Height (imperial measure): ______________

Is this person able to participate in an active camp and/or recreation program? Yes No

(Examples of camp activities include hiking, fishing, boating, swimming, dancing, climbing, field games, etc.)

Any limitations or restrictions while at camp? Yes No If yes, describe on the line provided below:

____________________________________________________________________________________________________________________________

Any medical concerns to be monitored at camp? Yes No If yes, describe on the line provided below:

____________________________________________________________________________________________________________________________

(This includes allergies, asthma, heart conditions, blood pressure, blood sugar, weight, etc.)

Any meal plans or dietary restrictions to be monitored at camp? Yes No If yes, describe on line below:

_____________________________________________________________________________________________________________________________

(This includes puree, dietary supplement, food allergies and sensitivities, portion limitations, low carb, low calorie, etc.)

Comments: ___________________________________________________________________________________________________________________

Date of Physical Exam: _____________________________ Today’s Date: _____________________________

I have reviewed the relevant portions of the Camper Registration Packet and have discussed the camp program with the

camper’s parent/s or guardian/s or agent on their behalf. It is my opinion that the camper is physically and emotionally fit to

participate in an active camp program, except as previously noted. I am aware of all medications prescribed to this individual

and see no contraindications. This person can also receive all “as needed” medications and treatments checked, or indicated

on the MARS, when deemed necessary by Central Oklahoma Camp and Conference Center, Inc.

Health Care Professional’s Signature/Stamp: ______________________________________________________________________________

Name (please print): __________________________________________________ Phone Number: (______)________-______________

Page 1

Camper Name: ____________________________________________________________________________________________________

Last First Middle 2021

pounds feet & inches If using a physical outside of camp’s please provide camper’s weight: _____________ & height: ______________

camper's name: camper's weight: camper's height: Date DTP: Date DTaP: Date OPV: Date IPV: Date MMR: Date HiB: Date HepB: Date Rotavirus: Date PCV13: Date Varicella: Date HepA: Date Human Papillomavirus: Date MenACWY: Date MenB: Date Influenza: Date TET-TOX: Click if Camper has had the Inactivated Polio Vaccine: OffClick if Camper has had the Measles, Mumps, Rubella Vaccine: OffClick if Camper has had the HiB Vaccine: OffClick if Camper has had the HepB Vaccine: OffClick if Camper has had the Rotavirus Vaccine: OffClick if Camper has had the PCV13 Vaccine: OffClick if Camper has had the Varicella Vaccine: OffClick if Camper has had the HepA Vaccine: OffClick if Camper has had the HPV Vaccine: OffClick if Camper has had the MenACWY Vaccine: OffClick if Camper has had the MenB Vaccine: OffClick if Camper has had the Influenza Vaccine: OffClick if Camper has had the Oral Polio Vaccine: OffClick if Camper has had the TET-TOX Vaccine: OffClick if Camper has had a DTP vaccine: OffClick if Camper has had a DTaP vaccine: OffYes or No, has Camper had a TB skin test: Date of most recent TB test, if had one: Positive or Negative, what was the result of the most recent TB test?: Please explain if it was a Positive result: