Summer Sonatina Insurance/Diet/Allergy Form

Parents must complete all sections of this form and attach an official signed doctor form no later than June 1, 2025.

NOTE: If you can't provide an electronic copy of your doctor's statement to attach here:

Please submit this Medical form in its entirety and send the doctor's statement separately to us via email at summer@sonatina.com or mail to:

Summer Sonatina,
5 Catamount Lane,
Bennington, VT 05201

Camper Name*

First NameLast Name

Camper Birth Date*

Date

city of birth* and state of birth*

Name of primary insured: (If no insurance, name of parent/guardian responsible for medical bills)*

First NameLast Name

Date of birth primary insured:*

Date

Name of employer of primary insured:*

Insurance Company Name:*

Group/Plan/Account #:*

ID #:*

If camper is not covered under any health insurance, you as a parent (or legal guardian) agree to cover any medical emergencies during your child's stay. Do you agree? Your agreement will count as your signature.*

YES

It is my understanding that Summer Sonatina is 1.5 miles from the ER of Southwestern Vermont Medical Center as well as from an Urgent Care facility, and that every effort will be taken to contact parent/guardian before any action is taken. However, in case we are not reachable and immediate action is required, I hereby authorize Summer Sonatina to arrange for any such emergency and/or dental treatment. I further agree to pay for any and all such treatment. Do you agree? Your agreement will count as your signature.*

YES

Camper allergies that may need attention:*

Camper dietary restrictions:*

Student medical problems or restrictions on activities:*

Medications to be taken during camp including dosage and times of day to dispense: Each container of medicine must be marked with student name and placed in a gallon-sized clean Ziploc baggie with their name prominently displayed on the baggie. Also include in the baggie what times to dispense. Medications will be kept in a special cabinet and supervised by staff. *

Over-the-counter medications (i.e., Advil, Tylenol, Benadryl, cough drops, hydrocortisone cream) administration is authorized.*

YesNoOther

If "Other" please list over-the-counter medications that are authorized:

File Upload: Please attach an electronic copy of your doctor's statement of health? If not, mail to: Summer Sonatina, 5 Catamount Lane, Bennington, VT 05201 by June 1.

Summer Sonatina Insurance/Dietary/Allergy Form