Camper’s Name: LAST________________ FIRST (preferred)___________________________________ Gender ______ Current Grade _____ Birth Date ____________ Age when at camp _______________
Home Address:_________________________________________________________ ______________________________________________________________________
Custodial Parent/Guardian: _______________________ Relationship: _______________ Preferred Phones: (_____) _______ – _________ (_____) _______ – _________ Second Emergency Contact: ______________________ Relationship: _______________ Preferred Phones: (_____) _______ – _______ (_____) _____ – ____________
Allergies:
No Known Allergies
This Camper is Allergic to: Food Medicine Environment
Please describe below what camper is allergic to and the reactions seen: ______________________________________________________________________ ______________________________________________________________________
Diet/Nutrition:
This Camper eats a regular diet.
This Camper eats a regular vegetarian diet.
This Camper has special food needs. Please describe below: ______________________________________________________________________ ______________________________________________________________________
Restrictions:
I have reviewed the program and activities of the camp and feel the camper can participate without restrictions.
I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. Please describe below: ______________________________________________________________________ ______________________________________________________________________
Medical Insurance Information:
This camper is covered by family medical/hospital insurance: Yes No
Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable.
Insurance Company: __________________________
Group Number: ______________________ Plan/Policy Number: ______________________________ Subscriber: __________________________________________________________________________
Immunization History: (Only check ONE box)
Camper has been fully immunized and all shots required to attend school are up to date including a tetanus shot on _____/______.
Month/Year
Camper has NOT been fully immunized and I understand and accept the risks to child from not being fully immunized. ____________________________________________________________________________________ Signature of Custodial Parent/Guardian Date Relationship to Camper
Medication:
Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.
This person takes NO medications on a routine basis.
This person takes medications as follows:
Med #1 ________________ Dosage ______ Specific times taken each day ______________________ Reason for taking ____________________________________________________________________ Med #2 ________________ Dosage ______ Specific times taken each day ______________________ Reason for taking ____________________________________________________________________
Med #3 ________________ Dosage ______ Specific times taken each day ______________________ Reason for taking ____________________________________________________________________