Camper Medical Form (To be completed by physician.) (Please print this form and mail to Lyle Jepson, Director at the address below.) (802) 247-6611 Camp Thorpe 680 Capen Hill Road Goshen, VT  05733 cthorpe@sover.net                       Name: Date of Birth:   Problem list: Medications and doses: Date of last physical exam:: Date of last tetanus vaccination:: Allergies:: Height:: Weight:: BP::   Indicate if abnormal:   head lungs   eyes heart   ears abdomen   nose genitalia   mouth extremities   neck neurological   Does this person have physical, mental, or medical problems that would limit participation in a summer camp program?   Yes No     If yes, please explain::   Certification I certify that this person may:   not participate in camping activities     participate in routine camping activities     participate in camping activities with restrictions (please list):     Physician's Signature:: Date:: Physician's Name:: Physician's Telephone::