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Youth Camp Health History - Camper This form is required to participate in Summer Camp.
Event:
Start Date/Time:
End Date/Time:
Fee per Student:
Room:
*
- denotes required fields
Family Information
First Name:
*
Last Name:
*
Type
*
Aunt/Uncle
Brother
Father
Grandparent
Guardian
Mother
Nanny
Other
Owner/Director
Parent
Sister
Step Father
Step Mother
Home Phone:
Cell #:
Work #:
Email:
*
(Emails are kept confidential)
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NE
NC
ND
NH
NJ
NM
NY
NV
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip:
*
Students entered below will be added to your family's account
Add New Student #1:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
Birth Date:
*
(format=mm/dd/yyyy)
Name of School:
*
Allergies and/or Medications (Leave blank if NONE):
:
Date of Trial Class- $35.00 :
Desired Start Date for classes:
*
Notes :
Add New Student #2:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
Birth Date:
*
(format=mm/dd/yyyy)
Name of School:
*
Allergies and/or Medications (Leave blank if NONE):
:
Date of Trial Class- $35.00 :
Desired Start Date for classes:
*
Notes :
Add New Student #3:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
Birth Date:
*
(format=mm/dd/yyyy)
Name of School:
*
Allergies and/or Medications (Leave blank if NONE):
:
Date of Trial Class- $35.00 :
Desired Start Date for classes:
*
Notes :
Add New Student #4:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
Birth Date:
*
(format=mm/dd/yyyy)
Name of School:
*
Allergies and/or Medications (Leave blank if NONE):
:
Date of Trial Class- $35.00 :
Desired Start Date for classes:
*
Notes :
Add New Student #5:
(Show-Hide Details)
Student's First Name:
*
Last Name:
*
Student Gender:
*
Female
Male
Nonbinary
Birth Date:
*
(format=mm/dd/yyyy)
Name of School:
*
Allergies and/or Medications (Leave blank if NONE):
:
Date of Trial Class- $35.00 :
Desired Start Date for classes:
*
Notes :
Questions/Options:
Child's Name
*
Primary Residence
*
Emergency Contact (Parent or Legal Guardian) Name:
*
Emergency Contact (Parent or Legal Guardian) Phone Number:
*
2nd Emergency Contact (Other than Parent Above) Name:
*
2nd Emergency Contact (Other than Parent Above) Phone Number:
*
Primary Care Physician or other provider of medical care:
*
Primary Care Physician or other provider of medical care - Phone Number:
*
HEALTH INFORMATION: Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?
*
Yes
No
If YES, Explain:
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child’s camp experience is positive?
*
Yes
No
YES, Explain:
IMMUNIZATION: Does the camper residing within the USA, a US territory, or the District of Columbia have any immunization exemptions because parental or guardian objection or medical contraindication?
*
Yes
No
If YES, List:
For campers who reside outside the United States, a United States territory, or the District of Columbia: Attach record of vaccination or immunity on Department form MDH-896.
Yes
No
Additional Information:
Other Questions/Comments:
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