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Medical Information and Emergency Form

Parent or Guardian's Full Name:

Email Address:
Number of Campers:
Address:

Name:
Phone:

First Parent's Name:
First Parent's Phone:
Second Parent's Name:
Second Parent's Phone:
Other Contact's Name:
Other Contact's Phone:
Other Contact's relationship to you:
Authorized Adults:

Name:
Child #1 Age:
Does Child #1 have any medical conditions?
Medical conditions:

Does Child #1 have allergies or allergic reactions to medications?
Allergies or allergic reactions:
Is Child #1 currently taking medications?
Medications:
Well-Camper Information:

Name:
Child #1 Age:
Does Child #2 have any medical conditions?
Medical conditions:

Does Child #2 have allergies or allergic reactions to medications?
Allergies or allergic reactions:
Is Child #2 currently taking medications?
Medications:
Well-Camper Information:

Name:
Child #3 Age:
Does Child #3 have any medical conditions?
Medical conditions:

Does Child #3 have allergies or allergic reactions to medications?
Allergies or allergic reactions:
Is Child #3 currently taking medications?
Medications:
Well-Camper Information:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

February 27, 2022 7:50 pm PST

Medical Information and Emergency Form Uploaded by Colette Blair - [email protected] IP 216.176.190.58