Summer Camp Medical Form

Camper's Name *

What weeks of camp is your child attending? *

Address *

City, State & Zip Code *

Parent/Guardian Names *

Cell Number *

Home Number

Work Number

Emergency Contact & Phone Number *

Relationship to Camper *

Medical Insurance Company *

Your personal medical policy is your primary coverage. All registered campers are covered by excess coverage accident insurance while at camp.

Policy Holder *

Policy #: *

Group #: *

Pediatrician's Name *

Pediatrician's Phone Number *

Allergies

Current Medications

Do we have permission to give your child Children's Tylenol?

Are there any special instructions or things we should be aware about your child? *

Do we need to administer any medication to you child during camp hours? *

If yes, we will need you to fill out an additional form in the front office.

Will someone other than the parents/guardian being picking up your child from camp? *

If yes, we will need you to fill out an additional form in the front office.

Phone