HEALTH STATEMENT

I attest to the fact that my child____________________________________________is in good physical condition and that there have been no changes in his/her physical condition since undergoing a physical on ________________________________.  My child has also received his/her required immunization for school attendance.  If your child has not had a physical examination within the last year, you must complete the waiver forms below.

My child is physically able to participate in the activities involved in C.I.A. Summer Camp with the following limitations:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

My child is free from any illness or communicable disease at this time _________ (parent/guardian initials)

If your child has any allergies, including food allergies or sensitivities please list below.  If he/she does not have any allergies please initial here___________ (parent/guardian initials)

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

Should any of the above conditions change, I will promptly notify the camp director.

____________________________________            __________________________

Parent/Guardian signature                                          Date

PHYSICAL EXAM WAIVER

I am aware my child__________________________________________has not had a physical examination within the last year.  I do not wish for my child to have another physical exam at this time.

___________________________________              ______________________________

Parent/Guardian signature                                          Date

updated 04/02/08