Medical History & Consent for Treatment

1Camper Information > 2Medical History > 3Insurance Information > 4Medication Consent > 5Consent for Treatment
Camp Registration Form ID (HIDDEN/AUTOFILLED)
Camp Registration Form Entry Number (HIDDEN/AUTOFILLED)
Camp Name *
Start Date Start Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Camper Information
Name of Camper Name of Camper * First Last
Date of Birth Date of Birth * / MM / DD YYYY
Age
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent / Guardian Name *
Same Address? *

Same Address? Yes No
Parent / Guardian Address Parent / Guardian Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary Phone Number Primary Phone Number * - ### - ### ####
Additional Phone Number Additional Phone Number - ### - ### ####
Emergency Contact

In case of emergency, if parent/guardian cannot be reached, name of person to notify or to whom we can release camper in your absence.
Name
Relationship
Phone Number Phone Number - ### - ### ####