City Kids Camp - Ages 7-12
Camp Victory - July 1-3, 2019
Email address *
Child's First Name *
Your answer
Child's Last Name *
Your answer
Date of Birth *
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DD
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Gender *
T-shirt Size *
Camper lives with: *
Address *
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Parent/Guardian's First & Last Name *
Your answer
Primary Emergency Contact Name *
Your answer
Primary Emergency Contact Number *
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Medications (including over-the-counter medication) *
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Will your child bring medications with them to camp? If so, you must complete a separate medication form. (See a K-5 class leader for this form) *
Allergies *
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Click All Conditions that Apply *
Required
If any conditions apply, provide level (mild or severe), dates of latest occurrences, and any other important details *
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Limitations *
Provide an explanation of any limitations listed above *
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Do medical personnel and camp staff have permission to administer medication to your child? *
Name of Child's Physician *
Your answer
Contact Information for Child's Physician *
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Insurance Carrier *
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Insurance Policy Number *
Your answer
Name of Policy Holder *
Your answer
Other Considerations *
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