Please enable JavaScript in your browser to complete this form.
Insurance company *
Policy number *
Group number *
Physician's name *
Physician's phone *
Dentist's name *
Dentist's phone *
Please list: 1) each medication; 2) when it should be given (e.g. breakfast, lunch, dinner and/or bedtime); and 3) the amount that should be given. *
Please list all allergies your child has including drug, food, insect stings, asthma, etc., and accompanying symptoms. *
Please list medicine and reaction. *
Does your child have any behavior, physical, emotional, or mental health challenges we should be aware of?
Please elaborate
Has your child been diagnosed with any mental-health-related condition, including ADHD? If so, when was the diagnosis given and by whom?
Has your child ever been hospitalized for any reason? If so, when and for what reason?
Does your child have difficulty sleeping or urinate in bed? If so, please explain how you handle this at home.
How did school go last year? Any feedback about social, academic academic, or other challenges that would be helpful for counselors to know in navigating camp.
2nd Camper - Insurance company *
2nd Camper - Policy number *
2nd Camper - Group number *
2nd Camper - Physician's name *
2nd Camper - Physician's phone *
2nd Camper - Dentist's name *
2nd Camper - Dentist's phone *
Please list: 1) each medication; 2) when it should be given (e.g. breakfast, lunch, dinner and/or bedtime); and 3) the amount that should be given. *
Please list all allergies your child has including drug, food, insect stings, asthma, etc., and accompanying symptoms. *
Please list medicine and reaction. *
Does your child have any behavior, physical, emotional, or mental health challenges we should be aware of?
Please elaborate
Has your child been diagnosed with any mental-health-related condition, including ADHD? If so, when was the diagnosis given and by whom?
Has your child ever been hospitalized for any reason? If so, when and for what reason?
Does your child have difficulty sleeping or urinate in bed? If so, please explain how you handle this at home.
How did school go last year? Any feedback about social, academic academic, or other challenges that would be helpful for counselors to know in navigating camp.
3rd Camper - Insurance company *
3rd Camper - Policy number *
3rd Camper - Group number *
3rd Camper - Physician's name *
3rd Camper - Physician's phone *
3rd Camper - Dentist's name *
3rd Camper - Dentist's phone *
Please list: 1) each medication; 2) when it should be given (e.g. breakfast, lunch, dinner and/or bedtime); and 3) the amount that should be given. *
Please list all allergies your child has including drug, food, insect stings, asthma, etc., and accompanying symptoms. *
Please list medicine and reaction. *
Does your child have any behavior, physical, emotional, or mental health challenges we should be aware of?
Please elaborate
Has your child been diagnosed with any mental-health-related condition, including ADHD? If so, when was the diagnosis given and by whom?
Has your child ever been hospitalized for any reason? If so, when and for what reason?
Does your child have difficulty sleeping or urinate in bed? If so, please explain how you handle this at home.
How did school go last year? Any feedback about social, academic academic, or other challenges that would be helpful for counselors to know in navigating camp.
Is there any additional information that would aid our camp staff in taking care of your child?
Is there any additional information that would aid our camp staff in taking care of your children?
Relationship to Child:
Relationship to Children:
