Health Form 
Please fill out this form as it will allow us to create the best possible experience for your camper this Summer! If you have multiple Campers joining us, please fill out a separate form for each. 
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What is your child's first & last name? *
What Camp Group did you register your camper for?  *
Camper Pronouns?  *
What Size T-Shirt is Your Camper?  *
Any known food allergies? *
Will this camper be taking any medication?   *
Is the Camper covered by family medical insurance?
 *
Insurance Carrier Name:
 *
Group Number on Plan:
 *
Is there anything else that you would like us to know about your child?
 *
Authorized Pick-Up / Emergency Contact 1

Please List: 

First/Last Name: 
Phone Number:
Relationship to Camper: 
 *
Authorized Pick-Up / Emergency Contact 2 

Please List: 

First/Last Name: 
Phone Number:
Relationship to Camper: 
 *
Authorized Pick-Up / Emergency Contact 3

Please List: 

First/Last Name: 
Phone Number:
Relationship to Camper: 
 *
If there are any behavioral needs that the Camp Office should be aware of, please fill out this form.   
How did you hear about MJCC Summer Day Camp? 
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This form was created inside of Portland Jewish Academy.