Junior Golf

Name*
First
Last

Email Address*

Phone Number*

Address
Street
City
State
Zip
Country

Gender

Emergency Contact

Emergency Contact #

Camp

Age

Grade in the Coming Fall

Date of Last Tetanus Shot

Parent or Guardian Name

Physician's Name

Physician's Number

Child's Allergies
Penicillin
Foods
Bee/Wasp

Other Allergies

Does Your Child Have an Epi-pen?

Is your child diabetic?

If yes, please describe

Is your child presently on medication?

If yes, please describe

Are there any other health concerns of which the staff should be aware

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