2018 Workcamp Health Form
Due April 2, 2018
General Information
First Name *
Participant First Name
Your answer
Middle Name
Participant Middle Name
Your answer
Last Name *
Participant Last Name
Your answer
Workcamp *
Which workcamp are you attending?
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Address *
Street
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent/Guardian
First and Last Name (youth participants only)
Your answer
Day Phone
of Parent/Guardian (if applicable) xxx-xxx-xxxx
Your answer
Evening Phone
of Parent/Guardian (if applicable) xxx-xxx-xxxx
Your answer
Parent/Guardian Address (if different than above and if applicable)
Street
Your answer
Parent/Guardian City
Your answer
Parent/Guardian State
Your answer
Parent/Guardian Zip Code
Your answer
Emergency Contact Person *
First and Last Name (Different than parent/guardian)
Your answer
Relationship *
to participant
Your answer
Emergency Contact Day Phone *
xxx-xxx-xxxx
Your answer
Emergency Contact Evening Phone *
xxx-xxx-xxxx
Your answer
Insurance
Is the participant covered by family medical/hospital insurance? *
Carrier/Plan Name
If covered
Your answer
Group Number
If covered
Your answer
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