Child's Full Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Height
*
Weight
*
Hair Color
*
White
Blonde
Dark Blonde
Light Brown
Brown
Black
Red
Strawberry Blonde
Eye Color
*
Blue
Green
Brown
Hazel
Does your child have emergency medications that will need to be kept onsite at camp?
*
Medication Information
If you answered yes, please provide the medication name and details that will be administered regularly at camp.
Special Dietary Needs
*
Can your child effectively communicate his or her own needs?
*
Please provide detailed answers. so we may best support your child.
Other Illness, Medical Needs, Disabilities, or Accomodations
*
Please provide special instructions concerning your child, as necessary. If there are none, please write N/A.
Allergies
*
Please click ALL that apply
Allergy Information
*
Please provide detailed information on ALL allergies including what your child is allergic to, the reaction and if it is life-threatening. If your child has no allergies, please write N/A.
Does your child have emergency medications that will need to be kept onsite at camp?
*
Special Medicine Instructions
If you answered yes, please provide special instructions for allergy treatment medications or a detailed allergy action plan.
Additional Medical Information
*
In the space below please provide any additional Medical History information. If you do not have additional information please answer "none".
Medications
*
Please list all special medications taken at home or any additional pertinent information.
Physician’s Name
*
First Name
Last Name
Physician’s Phone
*
(###)
###
####
Office Name
*
In the case of such an emergency, I can be reached at:
*
(###)
###
####
Medical Insurance Address
*
If you do not have medical insurance please answer N/A.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Medical Insurance Phone
*
If you do not have medical insurance please answer N/A.
(###)
###
####
