Bay State Baseball Camp
Summer Camp Health Form
Name: _____________________________________________________DOB: ______________
Date of Last Physical Exam: _______________________________________
Does the applicant suffer from: Epilepsy ( ) Y ( ) N Diabetes: ( ) Y ( ) N Asthma: ( ) Y ( ) N
Allergies: ______________________________________________________________________
Height: ____________________ Weight: ___________________________B.P: _____________
Scoliosis Exam: nl __ abnl__ Hearing: pass ____ fail ___ Vision: pass _____ fail____
( ) Normal Completed Exam
( ) Abnormalities noted:
______________________________________________________________________________
The applicant is under care for the following conditions:
______________________________________________________________________________
The applicant takes the following medications:
______________________________________________________________________________
Restrictions of limitations:
______________________________________________________________________________
I have examined the applicant and have reviewed his/her health history. It is my opinion that he/she is physically able to
engage in all activities except as noted above.
Physician: _____________________________________________________________________
Date Form Completed: _____________
Address: ______________________________________________________________________
City: _______________________________ State: _____________ Zip: _____________
Immunizations Attached: ( ) Y