Medical Form: Lovage Summer Club 2024
Email *
What week(s) are you signed up for? *
Required
Child's Full Name *
Date of birth *
MM
/
DD
/
YYYY
Sex *
Food Allergies (please describe in detail) *
Other allergies (eg. seasonal, baby care products, sunscreen, etc.) *
Does your child have an Epi-pen for the above allergy? *
Will your child be bringing an Epi-pen to Summer Club? (If so, Lauren will be reaching out to you to discuss further)
*
Additional allergy or health information
*
Child's Approximate Height
Child's Approximate Weight
Primary Parent: Name *
Primary Parent: Phone Number *
Primary Parent: Relationship to Child
Secondary Parent: Name
Secondary Parent: Phone Number
Secondary Parent: Relationship to Child
Non-Parent Emergency Contact 1: Name (this is the first person we call in case of an emergency if we cannot reach a parent) *
Non-Parent Emergency Contact 1: Relationship to Child
*
Non-Parent Emergency Contact 1: Phone Number 
*
Non-Parent Emergency Contact 2: Name (this is the second person we call in case of an emergency if we cannot reach a parent)
*
Non-Parent Emergency Contact 2: Relationship to Child
*
Non-Parent Emergency Contact 2: Phone Number 
*
Pediatrician Name *
Pediatrician Phone Number *
Pediatrician Address *
Please add any other details we should know about your child's medical history? Ex: injuries, surgeries, phobias, skin conditions, etc. 
A copy of your responses will be emailed to .
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