Jijak Youth Camp 2019 Medical Release
*PLEASE FILL OUT ONE FORM FOR EACH JIJAK YOUTH CAMP PARTICIPANT*

Your medical information is confidential. Food allergies, insect bite or sting allergies, behavioral conditions, and medication frequency will only be shared with Jijak Youth Camp Leadership Staff and your child’s counselors.

Camp Dates: Monday, June 24 - Friday, June 28
Camp Location: Jijak | 2558 20th St. Hopkins, MI 49328
Registration Deadline: Friday, May 31 | 5:00 p.m.
Contact us at 269.397.1780 or youthcamp@glt-nsn.gov
Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Food Allergies/Type of Reaction
Your answer
Drug Allergies/Type of Reaction
Your answer
Insect Bite or Sting Allergies/Type of Reaction
Your answer
Other Conditions (Medical, Physical, Behavioral, Psychiatric or Social/Emotional Conditions)
Your answer
Immunizations
Immunizations must be up to date. Michigan residents will be confirmed. Out of state campers will need to submit
Immunization records with this medical release form.
Are the following immunizations current - DTap/Tdap, Flu, HPV, MCV4, MMR, Varicella? *
If no, what is not current?
Your answer
Diet: Is a medically prescribed, religiously restricted or vegetarian diet required?
Please Explain:
Your answer
Note:
Some special diets may require campers to bring their own food
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