2018 Suvelaager Health History Form
All sections must be completed by a parent, guardian, physician or self (if adult) as required by the New Jersey Youth Camp Safety Standards. All information must be current at the start of camp. Update any information that changes between the completion of this form and the start of camp with a new form. Medical information and health history provided will be kept with strict confidence by the camp administration.
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Emergency Contact (Parent or Guardian if minor) *
Your answer
Contact’s telephone *
Your answer
Primary Physician’s Name *
Your answer
Physician’s telephone *
Your answer
Medical Insurance
Your answer
Policy Number
Your answer
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