Child’s Name: _______________________________________ Age (as of 6/1/09): ________

Parent/Guardian: ______________________________________ Phone: ________________

Street Address: ____________________________________________________________

City/State/Zip Code: ________________________________________________________

Parent email address: _______________________________ Emergency Phone# _________

Camper Medical Information

Physician Name: __________________________________ Phone: ________________

Dentist Name: ____________________________________ Phone: ________________

Allergies: ________________________________ Disabilities: ________________________

Medications: _________________________________________________________________

We do not have medical staff on duty and cannot administer medications.

Due to the nature of camp activities, we strongly encourage that your child’s tetanus shot be current.

Date of last tetanus shot: _______________