Health History

Camper Information

Child's Information

Child's First Name

Child's Last Name

Child's Birthdate

Emergency Contact Information

First Emergency Contact (Parent or Legal Guardian):

First Name

Last Name

Contact Phone:

2nd Emergency Contact Name OTHER than listed above:

First Name

Last Name

Contact Phone:

Child's Physician:

Physician's Phone:

Health Information

Are there any health concerns including physical, cognitive, psychiatric, behavioral or special needs concerns?

If Yes, please explain:

Does this child need any medications during camp hours?

If Yes, Please list:

Are you aware that all medications must be self administered except for emergency epi-pen use?

Are you aware, if your child is bringing medication to camp, you must also provide a medical authorization form completed by your doctor and turned in to our office 7 days in advance?

Does this child have any dietary restrictions, allergies or special dietary needs?

If Yes, please let us know about them:

Keep in mind that we try to be a nut free camp, but some children may bring nut containing food in their lunches/snacks without us knowing. What type of eating environment would you like your child to eat in?

Immunization Information

Does the child reside in the United States, a United Territory, or the District of Columbia?

If yes, which State/Territory do they reside?

What country does the child reside?

All campers who reside outside of the United States, must provide our office with a completed DHMH-896 form (record of vaccination or immunization) 7 days prior to their first day of camp.

Is the camper exempt from any immunizations?

If yes, please explain their exemption:

Our camp is a Peanut-free and Nut-free environment. Please select to indicate you are now aware of this policy.

Your Information

Name of person completing this form:

First Name

Last Name

By inserting my name above, and selecting "Yes" below, I confirm that I have completed all of the above information accurately.

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We are OPEN for all programs on MLK Monday

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