First Name*Last Name*
eMail Address*Phone No.*
AddressCity
StateZip Code
GenderEmergency Contact
Emergency Contact #Camp
AgeGrade in the Coming Fall
Date of Last Tetanus ShotParent or Guardian Name
Physician's NamePhysician's Number
Child's AllergiesPenicillinFoodsBee/Wasp
Other AllergiesDoes 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
Comment
Please fill in all fields.