Pinehurst Country Club

In our ongoing efforts to ensure that your child has all necessary medical forms which will support our
program in providing a healthy and safe environment for your child, please complete the following:

Further medical forms and authorizations are required for:

Children needing any medication during program hours.

Children with severe allergies requiring medication.

Children with asthma that regularly require asthma medication during program hours.

Children with special health conditions.

To Be Completed by Parent/Guardian – please circle Yes or No

Child’s Name____________________________________________ Birthdate______________________

 Does your child have any allergies requiring emergency or routine medications or special attention?

Yes No

 Does your child have any food exclusions due to an allergic reaction to the food?

Yes No

If yes to either question above, please list food and your child’s reaction to exposure:

Food_______________ Reaction_____________________ Medication needed_____________________

 Does your child have Asthma and require emergency or routine medication during program hours?

Yes No

 Does your child have a special health condition (such as seizures, diabetes, feeding tube, oxygen, etc.)
that requires medication and/or special attention by center staff?

Yes No

If yes to any of the above, please download the appropriate Medical Forms, obtain doctor authorization
and return.

If no to any of the above, please sign statement below:

I will not have a health care plan filled out by my doctor because the allergies do not require medication
or special attention by the Kids Quest Camp staff and I hold the Pinehurst Country Club harmless.

Signature_____________________________ Initials____________ Date__________________________

The Children's Hospital School Health Program, Denver, CO 303.281.2790 rev.2007