2022 Active Kidz Sports Camp Registration

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

First NameLast Name
1st Emergency Contact Relationship:*
1st Emergency Contact Daytime Phone Number:*
Format: (000) 000-0000.
1st Emergency Contact Evening Phone Number if different:
Format: (000) 000-0000.
2nd Emergency Contact Name:*

First NameLast Name
2nd Emergency Contact Relationship:*
2nd Emergency Contact Day Phone Number:*
Format: (000) 000-0000.
2nd Emergency Contact Evening Phone Number if different:
Format: (000) 000-0000.
Doctors Name or Medical Clinic:*
Doctor's Phone Number:

Area CodePhone 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)*
YesNo
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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