Medical Information Form

Use this online form to submit medical information for a participant attending a program. You can also download a PDF version to print and send to ksantor@burlingtonvt.gov. Click here for the Medication Authorization Form

Medical Information Form
One form per condition
Participant's Name*
First Last
Date of Birth*
MM slash DD slash YYYY

Medical Condition Details
Name of condition*

When was it diagnosed*

Is the condition well controlled or managed?*

Yes

No
What are the participant's typical symptoms?*

Are there any triggers or factors that make it worse?*

Is the participant currently taking any medications for this condition?*

Yes

No
If yes, please list them

Will any medication need to be administered during the program?*

Yes

No
*if yes, then please complete a medication administration form
Are there any restrictions on activities or precautions needed due to this condition?*

Yes

No
If yes, please list them

Is any additional support or accommodations needed for participation in the program?*

Is there any other information that would help staff provide the best care and support for the participant?

Any specific tips or strategies that have worked in managing the medical condition in similar settings (e.g., school, daycare, previous camps, other programs)?

Emergency Details
What is the treatment plan in case of an emergency related to this condition?

What are the signs that require immediate medical attention?

What specific actions should be taken if the participant experiences a flare-up or worsening of the condition?

Prescriber’s Information
Primary Care Provider Name

Phone Number

Specialist Name (if applicable)

Phone number

Permission to Seek Care
I hereby give permission for camp staff to seek medical attention for the participant in case of an emergency. I also give permission for BPRW staff to contact the health professional(s) listed above about this condition if needed. I have fully read the program description and feel the participant will be able to participate fully in the program with this condition.
Parent or Guardian Name
First Last
Phone
Δ

Medical Information Form

Medical Condition Details

Emergency Details

Prescriber’s Information

Permission to Seek Care