Rockpoint Community Church CROSSROADS HEALTH FORM
It is very important that you fill out this form as completely as you can.Thank You!
Camper Name
First Name
Last Name
Emergency Contact
First Name
Last Name
Relationship to Camper
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please share any concerns you may have (anxiety, autism spectrum, development, etc.)
Does this camper have a severe allergy, and require special attention for it?
Yes
No
What is the allergy to [please list]
How severe is the allergy when exposed?
1
2
3
4
5
Unbothered Noticeable Potentially Fatal
May we administer medicine (provided by parent/guardian) in accordance with their allergic reaction plan? (We will always call first)
Yes
No
Submit
Should be Empty: