Name of Parent Filling Out Form *

First Name

Last Name

Name of Camp Attendee *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Emergency Contact 1 *

First Name

Last Name

Phone *

(###)

###

####

Emergency Contact 2

First Name

Last Name

Phone

(###)

###

####

Does your child have any medical issues we should be aware of? *

Yes

No

Does your child have any allergies we should be aware of? *

Yes

No

Is your child currently being treated for any injury or sickness, or taking any form of medication? *

Yes

No

Does your child have any special dietary needs? *

Yes

No