Humane Society of Charles County
2017 Summer Camp Registration Form
Child's Name (Camp Participant)
Your answer
Birthdate
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DD
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YYYY
Parent/Guardian Name
Your answer
Email
Your answer
Mailing Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Preferred Contact Phone Number
Required
Please list phone number
Your answer
How did you hear about our camps?
Camper Participants Health History
Please provide the following health history for your camper (DHMH-4768 (1/15)
1st Emergency Contact (Parent or LegalGuardian) Name and Phone Number
Your answer
2nd Emergency Contact (Other than Parent Above) Name and Phone Number
Your answer
Child's Physician Name & Phone
Your answer
Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?
If Yes, please explain:
Your answer
Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's experience is positive?
If Yes, please explain:
Your answer
If your child requires any medication during camp, please request a Medication Administration Authorization Form.
Immunization Information: Does the camper reside within the United States, a United States Territory or the District of Columbia?
If Yes, please list current State or Territory in which the child resides:
Your answer
Is this child (camp participant) exempt from any immunizations?
If Yes, please list them:
Your answer
For campers who reside outside of the United States, a United States territory or the District of Columbia please provide the country in which the child resides:
Your answer
For campers who reside outside of the United States, a United States territory or the District of Columbia please provide a copy of Department form DHMH-896 (record of vaccination or immunity)
Your answer
I am the parent or legal guardian of the child (camp participant) and verify that the Health Information is complete and accurate. DHMH-4768 (1/15). Signature:
Your answer
Date:
MM
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DD
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YYYY
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