Name

First Name

Last Name

Date of Birth

YYYY

Father's Name

First Name

Last Name

Mother's Name

First Name

Last Name

Parent Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Father's Place of Work

Father's Work Phone

(###)

###

####

Father's Cell Phone

(###)

###

####

Mother's Place of Work

Mother's Work Phone

(###)

###

####

Mother's Cell Phone

(###)

###

####

By checking this box, I hereby authorize my daughter to be treated by Certified Emergency Personnel (i.e. EMT, first responder, E.R. physician, dentist) in the case of an emergency, and if family physician/dentist cannot be reached.

Family Physician

Family Physician Phone

(###)

###

####

Family Dentist

Family Dentist Phone

(###)

###

####

Emergency Contact #1

Please give name, phone/cell number, and relationship to camper.

Emergency Contact #2

Please give name, phone/cell number, and relationship to camper.

Please list any allergies/medical problems, including those requiring maintenance medication to ensure medical personnel at camp have details of any medical condition. Doses and times for administering medication must be in writing (i.e. diabetic, asthmatic, seizure disorder). If none please write 'none'.

Also list medications you authorize camp personnel to administer in case of bee stings or minor cuts/headaches such as Tylenol, Advil, or Benadryl and their doses. If none please write 'none'.

By checking this box you agree to have camp personnel administer your daughter medication she is currently taking or in case she needs pain/allergy medication per the information on this form.

Date of last Tetanus Toxoid Booster

Other comments:

By checking this box you confirm and validate the information provided above.

Date

YYYY

Medical Release Form