2022 Active Kidz Sports Camp Registration

Emergency and Medical Information
Please provide 2 emergency conacts.
1st Emergency Contact Name *

First Name Last Name
1st Emergency Contact Relationship: *
1st Emergency Contact Daytime Phone Number: *
1st Emergency Contact Evening Phone Number if different:
2nd Emergency Contact Name: *

First Name Last Name
2nd Emergency Contact Relationship: *
2nd Emergency Contact Day Phone Number: *
2nd Emergency Contact Evening Phone Number if different:
Doctors Name or Medical Clinic: *
Doctor's Phone Number:

Area Code Phone Number
List any chronic illness and or physical limitaitons camp should know about: (If none, enter none) *
List any medical food allergies: (If none, enter none) *
List all current medications: (If none, enter none) *
Is camper covered by medical insurance: *

Yes No
Name of Insurance Company (enter none if no insurance): *
Policy Number (enter none if no insurance): *

2022 Active Kidz Camp Registration Form

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