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2019 Chalice Camp Health History Form
Email address *
Camper or Counselor *
Camper/Counselor Information
Please fill out one form per child.
Full Name *
Your answer
Unit (for camp use only--guardians leave blank)
Your answer
Physician/Health Insurance Information
Doctor's Name *
Your answer
Doctor's Address *
Your answer
Doctor's Telephone *
Your answer
Insurance Provider *
Your answer
Insurance Policy Number *
Your answer
Insurance Provider Address *
Your answer
Insurance Provider Telephone *
Your answer
Dentist Name *
Your answer
Dentist Address *
Your answer
Dentist Telephone *
Your answer
Medical Information
Please fill out as completely as necessary/possible. If a particular question doesn't apply, please respond with "N/A."
Are there any restrictions to your child's participation in a complete camp activity program? *
Your answer
Does your child have any illnesses, disabilities, or chronic conditions of which we should be aware? *
Your answer
Will your child be on any medication during the camp session? If yes, please specify. *
Your answer
Does your child have any allergies to foods or medications? If yes, please specify. *
Your answer
Additional Camper/Counselor Information
Is there anything we should know that will make this week successful and enjoyable for your child? *
Your answer
Additional Information or comments not covered by the above questions. *
Your answer
Permissions
Health and Care Permissions *
In case of medical emergency, I hereby give permission to the Camp Directors to secure proper medical treatment for my child listed above. In emergency cases, it is camp policy to make every reasonable effort to contact the parent/guardian immediately. I understand the medical information must be completed before my child's registration is considered completed. I understand that Chalice Camp is not responsible for my child’s personal property. I have read and I accept the policies and fees listed on the Chalice Camp application and registration forms. I represent that the statements made herein are true and accurate. Please type your full name and today's date if you are responding in the affirmative.
Your answer
Personal Information Permission *
I give permission for my child’s phone number and address to be used in a camper group list to be given to other campers.
Required
Visual Images Permissions *
I permit the use of photos, audio, quotes, stories, or video of my child for church print or web publicity (names omitted).
Required
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