Medical Emergency Form -

Medical Emergency Form

A separate Medical Emergency Form must be completed for each applicant. This form should be submitted with your Registration Form.

Camper Is Registered With: *

Junior Camp
Senior Camp
Hyphen Camp
Family Camp

Camper's Personal Information

Name *

First

Last

Gender *

Date Of Birth *

Age *

Home Phone

Mobile Phone *

Address *

Address Line 1

City

State

Zip Code

Emergency Contacts

List two emergency contacts.

Name *

First

Last

Relationship To Camper *

Phone *

Name *

First

Last

Relationship To Camper *

Phone *

Camper's Physician Information

Physician Name *

First

Last

Physician Phone *

Camper's Dentist Information

Dentist Name *

First

Last

Dentist Phone *

Camper's Insurance Information

Do You Have Hospitalization Insurance Coverage? *

Yes
No

Your Insurance Company: *

Your Policy Number *

Do you have any medication allergies, other allergies, medical conditions, or disabilities that require special attention? *

Yes
No

Please Explain *

Is The Camper 18 Years Of Age Or Older? *

Yes
No

Parent/Guardian Information

Parent/Guardian Name *

First

Last

Home Phone

Mobile Phone *

Signatures

Camper's Signature - (If you are 18 years of age or older) *

Clear Signature

"I authorize a camp nurse or staff member to make emergency medical care decisions on my behalf, including medical attention at a medical facility, if I am incapable of making an informed decision myself due to injury or illness."

Parent/Guardian Signature - (for newborns through 17 years of age): *

Clear Signature

"I authorize the providing of medical services in the event my child becomes ill or injured. I also authorize medical attention at a medical facility if deemed necessary by a camp nurse or staff member."

Medication Information

LIST MEDICATIONS FOR: All Jr. Campers (6-12 years of age) | All Sr. Campers (12-17 years of age) | All Hyphen Campers (high school graduates through 17 years of age)

Does The Camper Take Any Medications? *

Yes
No

Medication Information *

Please List: Name of ALL medication(s) | Dosage(s) and time(s) medication(s) is/are taken.