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Emergency Information Form
Email address *
VBS Camper Name (First and Last) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Home Address *
Your answer
Parent Name *
Your answer
Parent Number *
Your answer
2 other contacts who can pick up your camper.(Name and Number) *
Your answer
If we are unable to reach in you in an emergency, who do we call? (leave 2 contacts)
Your answer
Physician (Name and Contact Info)
Your answer
Does your child have allergies to: *
Required
Please specify the above allergies.
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Is medication needed for any of the above allergies?
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Are there any foods your child is not able to eat? *
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Does your child suffer from, or has ever experienced, or is being treated currently for any of the following:
Does your child wear
Please list and explain any major illnesses your child experienced during the last year.
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Should your child’s activities be restricted for any reason?
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Anything else we should know about your child? *
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