Emergency Medical Form - Summer Camp
All fields required. Enter "NA" for not applicable.
Student Last Name, First Name *
Your answer
Date of birth *
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DD
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YYYY
Parent/Guardian 1 name *
Your answer
Relationship to student *
Your answer
Parent Mobile phone *
Your answer
Place of employment *
Your answer
Occupation *
Your answer
Email address *
Your answer
Parent/Guardian 2 name *
Your answer
Relationship to student *
Your answer
Parent 2 Mobile phone *
Your answer
Place of employment *
Your answer
Occupation *
Your answer
Email address *
Your answer
Alternate contact name *
Your answer
Home phone (Alternate Contact)
Your answer
Cell phone (Alternate Contact) *
Your answer
Work phone (Alternate Contact)
Your answer
Please specify any health problems or Allergies *
Your answer
Please state any medications presently in use *
Your answer
Primary care physician *
Your answer
Phone number (Physician) *
Your answer
Medical insurance company *
Your answer
Policy number *
Your answer
In the event of a serious accident or one which we feel should have immediate attention, do we have your permission to take your son to the local emergency room, if we are unable to contact you? *
Do you give permission for emergency medical or surgical (stitches) treatment of your son? *
By typing your name here, you agree that all information above is accurate and that this is acting as your signature. *
Your answer
Date signed *
MM
/
DD
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YYYY
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