Registration
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*
Home Phone: Cell #: Work #:
Email:* (Emails are kept confidential)
 
Address: *
City: * State: * Zip: *
Emergency Contact Perrson and Phone #
 
 
Students entered below will be added to your family's account
 
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?*
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, 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?*
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.
 
Additional Information:
 
 
Other Questions/Comments: