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Kids Summer Camp Information Sheet

Please fill out this form accurately to ensure the safety and well-being of your child during their time at camp.

Student's Full Name

Date of Birth

Current Grade

Allergies/Dietary Restrictions

Authorized Persons for Pickup: (Please list individuals authorized to pick up your child. Photo identification will be required.)

Full Name

Relationship

Phone Number

Would you like to add one more authorized person for pick up?

Would you like to add one more authorized person for pick up?

A

Yes

B

No

Emergency Contact: (In the event of an emergency, please provide a contact who can be reached immediately.)

Full Name

Relationship

Phone Number

Medical Information:

Primary Physician

Phone Number

Medical Insurance Provider

Policy Number

Emergency Medical Facilities: (Write down the preferred hospital or clinic in case of emergency.)

Additional Notes or Special Instructions: (Please provide any additional information or special instructions regarding your child's health or well-being.)

By completing this form, you acknowledge that the information provided is accurate to the best of your knowledge and authorize camp staff to act on behalf of your child in case of emergency.

By completing this form, you acknowledge that the information provided is accurate to the best of your knowledge and authorize camp staff to act on behalf of your child in case of emergency.

I accept