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Camp Registration Form

Please provide the following medical information for your child:
NAME OF CAMPER line
Primary Emergency Contact  
Name line
Relationship line
Phone Number(s) line
Secondary Emergency Contact  
Name line
Relationship line
Phone Number(s) line
Allergies (medications, food, bee sting, poison ivy, etc)
Please describe the nature of the allergic reacation (rash, hives, difficulty breathing, etc.)
 
Injury History (eg. recent sprains, fractures)
 
Medical Conditions (eg. asthma, diabetes, cardiac disorders, seizure disorders, etc.)
 
Medications Currently Taking
 
Date of Last Tetanus Shot
 
Additional Medical Related Notes
 
Please return this form with a copy of your medical insurance card (front and back) and any outstanding balance (if due).