Camper Confidential Information Form

Camper Confidential Information Form

American Legion Auxiliary Junior Camp
Camper's Information

Please help us assist your child with their camp experience by letting us know a little bit about the camper.
Camper's Name :

First NameLast Name
Well-Liked Nickname :
What name does your child prefer to be called?
Birth Date :

MonthDayYear
Date
School and Grade :
Camper's Address :

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone :

Area CodePhone Number
What size Camp Shirt does your Camper wear? (Adult Sizes)

XSSmallMediumLargeXL2Xl3XL
Camper's Photo :

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Parent/Emergency Contact Information
Parent/Emergency Contacts Name :

First NameLast NameRelation to Camper
Phone Number :

Area CodePhone Number
Parent'/Emergency Contacts Email Address
matthew@example.com
Parent/Emergency Contacts Name :

First NameLast NameRelation to Camper
Additional Phone

Area CodePhone Number
Parent'/Emergency Contacts Email Address :
matthew@example.com
Please list any other information you feel will help us better serve your child :
Physician Information
Physicians Name ?
Physicians Address ?
Physicians Phone Number

Area CodePhone Number
Hospital of Choice near Newton Iowa.
Camper's Health Information
Camper's Insurance Information :

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Campers Health Insurance Company
Campers Health Insurance Policy number
Campers General Health Condition?
Does our camper have appendix?
Does our camper have tonsils?
Date of last tetanus shot.

MonthDayYear
Date
Does our camper wear glasses or contact lenses please advise.
Does our camper get her feelings hurt easily?
Does our camper have any special fears ?
Does your camper experience nightmares, sleepwalking in their sleep ?
Does your camper have any allergies? *
Please explain the allergies:
Does your camper have any food allergies ?
Please explain the allergies:
Recent Illness or Injury (Describe)
List all medications (including over-the-counter and prescription and why they are taking the medication.
Any over-the-counter medications your child should NOT be given?
Does your camper have any dietary restrictions ?
Please explain the dietary:
Any other medical information that we need to know :
Name and Full address of your Local newspaper!
Unit Number and Town if you belong to the Auxiliary!
Disclaimer

I certify that I am the parent/legal guardian of the above-named minor. The above-named minor has my consent to attend the Iowa American Legion Junior Auxiliary Camp from June 8, 2025, through June 13, 2025. I designate the Junior Camp Nurse to authorize and consent to any examination, medical/surgical diagnosis, treatment, admission to hospital, and related care for the above-named minor. This authorization is to be made only after a reasonable attempt has been made to contact me. I agree to accept financial obligations for any unwarranted damage done by the above-named minor during the effective dates of this authorization. I authorize the Junior Camp Director to send the above-named minor home at my expense if this becomes necessary. I give consent for her to participate in any field trip which is part of Junior Camp. I agree to accept all residual legal and financial responsibilities from this agreement.
Date

MonthDayYear
Date
Parent/Guardian's Signature :

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Camper Confidential Information Form

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