Health History

Camper Information

Child's Information

Child's First Name

Child's Last Name

Child's Birthdate

Please click below on the week(s) of camp(s) your child is registered to attend

Week #1

June 15th-June 19th

Week #2

June 22nd-June 26th

Week #3

June 29th-July 3rd

Week #4

July 6th-July 10th

Week #5

July 13th-July 17th

Week #6

July 20th-July 24th

Week #7

July 27th-July 31st

Week #8

Aug 3rd-Aug 7th

Week #9

Aug 10th-Aug 14th

Week #10

Aug 17th-Aug 21st

Team Week

August Team Week

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. Then click the link below this box to print and fill out the exemption form.:

Click here to Print exemption form
This form will need to have the child information filled out at the top of the first page. Then at the bottom of the first page there is a place to fill out for excemptions.

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.

Please provide your signature:

Provide signature above. Works best on mobile devices.

Attention:

A message to our clients regarding our temporary suspension of programs is noted below.