Name
First Name
Last Name
Age
Date of Birth
/
Month
/
Day
Year
Date
Gender Birth
Grade (Fal 19)
Address
Mailing address
Street Address Line 2
City
State
Zip
Home Phone
Parent E Mail Address
example@example.com
Emergency Number or Parent Cell
Parent/Guardian
Parent / Guardian Work Number
Insurance Carrier
Insurance Phone Number
Policy Number
Group Number
Insured's Name
List Exceptions
Does the Camper Have
Heart Trouble
Siezures
Asthma
Hernia
Lung Trouble
HIV/AIDS
Allergies
Diabetes
Other
Other
Name of Medicine
Exact Dosage
For Treatment of
Name of Medicine
Exact Dosage
For Treatment of
Name of Medicine
Exact Dosage
For Treatment of
Time - Medicine #1
Medicine #1
Time - Medicine #1
Medicine #1
Time - Medicine #1
Medicine #1
Time - Medicine #2
Medicine #2
Time - Medicine #2
Medicine #2
Time - Medicine #2
Medicine #2
Time - Medicine #3
Medicine #3
Time - Medicine #3
Medicine #3
Time - Medicine #3
Medicine #3
Is student compliant in taking mediciation
Yes
No
Parent/Guardian Signature (required regardless of age)
Relationship
Is there any information we should have regarding the welfare of this camper (handicaps, restrictions on activities, diets,
Camper's Name
Church & City
ST ROBERT FIRST ASSEMBLY OF GOD / ST ROBERT
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