OBH CHILTERNS PONY CLUB – CAMP 2016
Contact, Medical, and Veterinary Sheet
(This form must be returned with the application form)
Contact Information
It is essential that we can contact you at all times during camp. We expect a parent/guardian to be contactable in case of an
emergency and be available for non-urgent care/treatment. Please give relevant numbers as follows:
1st Contact Name
Tel Daytime
Tel Mobile
Relationship
Tel Evening
Email
2nd Contact Name
Tel Daytime
Tel Mobile
Tel Evening
Email
Medical Information
Does your child suffer from any of the following medical conditions? Please cross out as appropriate.
Dyslexia
Hearing defects
Vision defects
Heart/lung disorder
Nose bleeds
Epilepsy/fainting
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Any skin complaint
Bone/joint impairment
Are contact lenses worn?
Gastro-intestinal disorders
Asthma
Gynaecological disorders
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Migraine
Diabetes
Ear, nose & throat
Are braces worn?
Hay fever
Allergy to drugs/food
If answered Yes to any of the above, please specify:
Please specify any other relevant medical condition (attach a separate medical information note if necessary):
Does he/she regularly take any form of medication? Yes / No If so, what?
Are there any current injuries/recent operations/medical treatments? Yes / No
If so, please explain:
Any previous operations, eg, appendix. Yes / No If so, please explain:
Religion – if applicable to medical treatment
Date of last tetanus injection
Name of your GP
Surgery telephone number
Surgery address
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Vet Information
Please list below details for your horses vet. We expect to be able to contact your vet at all times during camp. Please give
relevant numbers as follows:
Vet Practice
Address
Telephone
Your Vets Name
Does your horse
have any medical
conditions we
should be aware of