SummerSault Camp 2021 Camper Health Information

Emergency Information
Camper's Pediatrican Name *
Pediatrician Phone *

Area Code Phone Number
Camper's Dentist Name *
Dentist Phone *

Area Code Phone Number

Medical Emergency Contacts

If neither parent can be reached, please list at least one alternate contact who can help direct your child’s medical care.
In a medical emergency, if neither parent can be reached, please contact the following person(s):
Medical Emergency Contact 1 Name *

First Name Last Name
Relationship to Camper *
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Email *
example@example.com
Medical Emergency Contact 2 Name

First Name Last Name
Relationship to Camper
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email
example@example.com

Consent to Share Important Information with Camp Staff

The electronic signature below and its related fields are treated by SummerSault like a physical handwritten signature on a paper form.
SummerSault at The Town School may share important information on my child’s Health Form with relevant Faculty/Staff *

I agree
Digital Signature *

First Name Last Name
Date *

Month Day Year
Date
Consent to Treat Digital Signature

The electronic signature below and its related fields are treated by SummerSault like a physical handwritten signature on a paper form.
IN CASE OF AN EMERGENCY and if SUMMERSAULT AT THE TOWN SCHOOL is unable to contact either parent or guardian, I give permission for the school to secure additional medical advice and treatment at a recognized local hospital. *

I agree
Digital Signature *

First Name Last Name
Date *

Month Day Year
Date
Other Information
Is there any other health information we should have about your child for camp this summer?
Should be Empty: