Participant Name:________________________________________________________________
Parent’s Name:__________________________________________________________________
Address:_______________________________________________________________________
Phone #1:__________________________________ Emergency__________________________
Phone #2:__________________________________
Name two other people to contact in case of an emergency:
Name, Address, Phone:___________________________________________________________
Name, Address, Phone:___________________________________________________________
Age of Participant:_______________________________________________________________
Allergies (Including Food Allergies and Problems):_______________________________________
______________________________________________________________________________
Medications:____________________________________________________________________
Insurance company:______________________________________________________________
Insurance Group #:___________________________ Insurance ID #_______________________
I give a Camp Counselor and LPN permission to accept medical treatment for my child
if I am unable to be reached from August 11, 2011 to August 12, 2012.
Parent Signature:________________________________________________________________
Date:__________________________________________________________________________
