Medical Data
Arkansas Vault Club ~ Summer Camps 2020
Name and date of birth? *
Your answer
Check any that apply. These screening questions will be asked again at check in. *
Required
List emergency contact/number and insurance information. *
Your answer
Do any of these apply to the camper? *
Required
If you checked any of the above or 'other', please explain.
Your answer
Does the camper have specific dietary needs (vegetarian, lactose intolerant, etc)? If yes, explain. *
Your answer
Any further information we need to know?
Your answer
Parent/Guardian Authorization: By signing my name below I attest the personal and medical information is correct and complete as far as I know. The person described has my permission to engage in all camp activities. I give permission to the camp to provide routine health care, administer prescribed medications, and seek emergency medical treatment including ordering x-rays , routine tests, and treatment. I agree to the release of any records necessary for insurance purposes. I give permission to the camp to arrange necessary related transportation for me/my child.In the event that I cannot be reached in an emergency, I give permission to the physician selected by the camp to secure and administer treatment, including hospitalization for the person named above. *
Your answer
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