Medical Information and Emergency Form | Canyon Arts & Creek Camp

2025 Medical Information and Emergency Form

To complete our enrollment process, all registrants must fill out and submit a Medical Information and Emergency Form for each family.

* = Required Fields

Parent or Guardian's Full Name*
First Last
Email Address*
Please use the email address that you submitted for registration.
How many campers do you have?*
Home Address*
Street Address City State ZIP Code
Regular Physician
Regular Physican's Name*
First Last
Physican's Phone*
Medical Information for Child #1
Name
First Last
Child #1 Age:
Does Child #1 have any medical conditions?*
Medical Conditions
Please list medical conditions for Child #1 (asthma, diabetes, epilepsy, etc.)
Click on + to add multiple conditions.
Does Child #1 have any allergies or allergic reactions to medications?*
Allergies and allergic reactions to medications*
Please list Child #1's allergies and include any allergic reactions to medications.
Click on + to add multiple conditions.
Allergy Item Allergic Reaction
Is Child #1 currently taking medications?*
Medications
Please list your child's medications.
Click on + to add multiple conditions.
Well-Camper Information
Please describe any additional medical, behavioral, social/emotional support needs that we should be aware of in order to assist your child in having the best possible camp experience:
Insurance Details*
Insurance Company Medical Number
Medical Information for Child #2
Name
First Last
Child #2 Age
Does Child #2 have any medical conditions?*
Medical Conditions
Please list medical conditions for Child #2 (asthma, diabetes, epilepsy, etc.)
Click on + to add multiple conditions.
Does Child #2 have any allergies or allergic reactions to medications?*
Allergies and allergic reactions to medications*
Please list Child #2's allergies and include any allergic reactions to medications.
Click on + to add multiple conditions.
Allergy Item Allergic Reaction
Is Child #2 currently taking medications?*
Medications
Please list your child's medications.
Click on + to add multiple conditions.
Well-Camper Information
Please describe any additional medical, behavioral, social/emotional support needs that we should be aware of in order to assist your child in having the best possible camp experience:
Insurance Details*
Insurance Company Medical Number
Medical Information for Child #3
Name
First Last
Child #3 Age
Does Child #3 have any medical conditions?*
Medical Conditions
Please list medical conditions for Child #3 (asthma, diabetes, epilepsy, etc.)
Click on + to add multiple conditions.
Does Child #3 have any allergies or allergic reactions to medications?*
Allergies and allergic reactions to medications*
Please list Child #3's allergies and include any allergic reactions to medications.
Click on + to add multiple conditions.
Allergy Item Allergic Reaction
Is Child #3 currently taking medications?*
Medications
Please list your child's medications.
Click on + to add multiple conditions.
Well-Camper Information
Please describe any additional medical, behavioral, social/emotional support needs that we should be aware of in order to assist your child in having the best possible camp experience:
Insurance Details*
Insurance Company Medical Number
Emergency Contacts
First Parent/Guardian Name*
First Last
First Parent/Guardian Phone*
Please include the area code and format your phone numbers as (555) 555-5555.
Daytime Number Evening Number
Second Parent/Guardian Name
First Last
Second Parent/Guardian Phone*
Please include the area code and format your phone numbers as (555) 555-5555.
Daytime Number Evening Number
Other Contact's Name*
First Last
Other Contact's Phone*
Please include the area code and format your phone numbers as (555) 555-5555.
Daytime Number Evening Number
Other Contact's Relationship to You (friend, neighbor, coworker, etc.)
Authorized Adults
Canyon Camp requires that all children be signed in and out by an authorized adult. Please list the adults authorized to sign you child in and out (other than Emergency Contacts listed above)
Authorization for Emergency Medical Treatment
Consent*
This information will be kept in the possession of Canyon Arts & Creeks Camp. A copy will be distributed to the person in charge of each activity in which the student/minor participates. Should the need arise this information will be given to the proper medical authorities.

I understand that in the case of illness or injury to my child, Canyon Arts & Creeks Camp will try to notify me, or the person I have listed above as an emergency contact. In case of medical emergency concerning my child, at a time when I or my listed emergency contact cannot be notified, I grant full power to the Canyon Arts & Creeks Camp to 1) arrange for the transportation of my child, whether by ambulance or otherwise, to a proper facility where emergency medical treatment would normally be administered, including but not limited to, an emergency room of a hospital, a doctor’s office, or a medical clinic; and 2) sign releases as may be required in order to obtain any medical or surgical treatment as is required in the judgment of medical authorities at the facility.

A child’s participation in camp activities, events, or programs conducted by Canyon Arts & Creeks Camp, its employees and agents (the “Camp”) involve inherent and unavoidable risks of physical injury or harm and, despite reasonable precautions, it is impossible for the Camp to enumerate or eliminate all possible risks or guarantee safety. For example, there are risks associated with all physical activities, sports and games, and the use of equipment, which may break, malfunction, or cause injury even when used as intended. DESPITE THESE RISKS, I AUTHORIZE MY CHILD(REN) TO PARTICIPATE IN ALL CAMP ACTIVITIES AND, ON BEHALF OF MYSELF, MY FAMILY, AND MY MINOR CHILD(REN), TO THE FULLEST EXTENT PERMITTED BY LAW, HEREBY WAIVE AND RELEASE ALL CLAIMS, DEMANDS, ACTIONS, CAUSES OF ACTION, COSTS, LOSSES, EXPENSES, MEDICAL BILLS, AND LIABILITIES OF ANY KIND OR NATURE (“CLAIMS”) INCLUDING BUT NOT LIMITED TO CLAIMS OF INJURIES, HARM OR LOSS ARISING FROM MY CHILD(REN)’S CAMP PARTICIPATION, CAMP ACTIVITIES, OR THE CAMP’S NEGLIGENCE, ACTION OR INACTION, WHICH MAY BE ASSERTED BY ANY OF US AGAINST THE CAMP, ITS STAFF, EMPLOYEES, AND AGENTS, AND I HEREBY AGREE TO INDEMNIFY, DEFEND AND HOLD THEM HARMLESS FROM ANY SUCH CLAIMS
I agree
Photo Release
Occasionally, Canyon Arts & Creeks Camp will photograph campers during our summer sessions. Photos may appear on our website at www.canyonartscamp.com. Photos are used for the purpose of illustrating and promoting the camp experience and our programs. We need your signature on file if you give permission to use photos of your child for promotional purposes.*
Occasionally, Canyon Arts & Creeks Camp will photograph campers during our summer sessions. Photos may appear on our website at www.canyonartscamp.com. Photos are used for the purpose of illustrating and promoting the camp experience and our programs. We need your signature on file if you give permission to use photos of your child for promotional purposes.
- I give permission to Canyon Camp to use photographs of my child(ren) while attending summer camp
- I do not give permission
Are you a spammer? Of course you're not!

Allergy Item	Allergic Reaction

Allergy Item	Allergic Reaction

Allergy Item	Allergic Reaction

2025 Medical Information and Emergency Form

To complete our enrollment process, all registrants must fill out and submit a Medical Information and Emergency Form for each family.

Regular Physician

Medical Information for Child #1

Medical Information for Child #2

Medical Information for Child #3

Emergency Contacts

Authorization for Emergency Medical Treatment

Photo Release