Healthy History Form for Summer Fun Days

Please complete the form below. We need this information on file before your child can participate in Summer Fun Days. There is also a paper copy of this form...we can accept the information in either the paper copy or through this online submission. We need separate forms completed for each child if you are registering siblings.

Please contact us if you have questions or need to further discuss your child's participation in Summer Fun Days 410-838-3042 belair@mygym.com

Thank you!

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	* required fields
*Parent First Name
*Parent Last Name
*Email
*Phone
*Child First Name
*Child Last Name
*Child Date of Birth
	+ Add additional child
	- Remove additional child
*Child First Name 2
*Child Last Name 2
*Child Date of Birth 2
	+ Add additional child
	- Remove additional child
*Child First Name 3
*Child Last Name 2
*Child Date of Birth 3
	+ Add additional child
	- Remove additional child
*Child First Name 4
*Child Last Name 4
*Child Date of Birth 4
	+ Add additional child
	- Remove additional child
*Child First Name 5
*Child Last Name 5
*Child Date of Birth 5
*Emergency contact person (other than parent): Name, phone number, relationship to child
*Other caregivers authorized to pick up my child: (if none type "none")
*Provide month and year of child's last tetanus (or DTP) shot:
*Is your child enrolled in a Maryland school? Yes or No. If Yes, please provide name of school. If no, provide a copy of immunization records to My Gym via email belair@mygym.com
*Child's Physician and Phone Number:
*Provide any medical, behavioral, psychological conditions, medications, dietary restrictions, allergies, or special needs that we need to be aware of:
*Please prove you are not a Robot. What is 40 + 5