Summer Zoo Camp 2023 Immunization Form

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* 1. Please complete the below information. One form per camper.

Parent/Guardian Last Name:

Parent/Guardian First Name:

Camper Last Name:

Camper First Name:

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* 2. Week of Camp: Date and Type of Camp (Summer Zoo Camp, Middle School Camp, High School Camp, or Summer Camp Overnight)

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* 3. Campers Age

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* 4. IMMUNIZATION CONFIRMATION

I confirm that this camper is current with all necessary immunizations required by TDSHS, the county public health office, and local school district.

Camper does not receive immunizations for religious/medical reasons.

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* 5. Camper has received the following immunizations: (Please check all that apply).

Tetanus Booster

Tuberculin (TB)

MMR

DPT

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* 6. Family Doctor: (Name and phone number).