Family Registration Form - Kids Cancer Care
Family Registration Form - Kids Cancer Care
Family Registration Form - Kids Cancer Care
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Headaches<br />
Convulsions / seizures<br />
Fainting spells<br />
Vision problems<br />
Glasses and/or contacts<br />
Hearing problems<br />
Wears hearing aids<br />
Asthma – non-medicated<br />
Asthma – takes medication<br />
Heart problems<br />
Blood clotting problems<br />
Stomach/bowel problems<br />
Skin problems<br />
Menstruation – has started<br />
Menstruation problems<br />
Diabetes<br />
Motion sickness<br />
Physical limitations or<br />
disabilities<br />
Uses physical aides<br />
(e.g. prosthetic, wheelchair,<br />
crutches etc)<br />
G-Tube/ NG –tube<br />
Bed wetting<br />
Other<br />
Please indicate if your child has experienced any of the following in the past:<br />
Concern: Camper 1 Camper 2 Camper 3 Camper 4<br />
Seizures/convulsions<br />
Heart/lung problems<br />
Blood clotting problems<br />
If you answered yes to any of the above you must expand on the information provided above and/or explain any<br />
other medical/physical areas of concern for your child:<br />
_____________________________________________________________________________________________<br />
_____________________________________________________________________________________________<br />
_____________________________________________________________________________________________<br />
_____________________________________________________________________________________________<br />
KCCFA <strong>Family</strong> Intake <strong>Form</strong><br />
Revised 6/6/10<br />
6
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