Camp Joy Medical Form

Emergency Contact #1*

First NameLast Name

Emergency Contact #1's Primary Number*

Please enter a valid phone number.

Emergency Contact #1's Secondary Number

Please enter a valid phone number.

Emergncy Contact #2

First NameLast Name

Emergency Contact #2's Primary Number

Please enter a valid phone number.

Emergency Contact #2's Secondary Number

Please enter a valid phone number.

Camper's Name*

First NameLast Name

Camp Attending*

JuniorMiddlerSenior

Date Of Birth*

Date

Height*

Weight*

Gender*

MaleFemale

Please list any chronic conditions (i.e. allergies, asthma, diabetes, heart conditions, seizures, etc.)

Are you up to date on your vaccines?*

YesNo

Please list the vaccines you have not completed or had.

Are glasses worn?*

YesNo

Any illnesses in the last two months?*

YesNo

Please list those illnesses.

Is the camper subject to: (check all that apply)

Allergies (to medicines) or special conditions to be watched for:

Emotional or behavioral disturbances:

Operations or Injuries:

Any physical or emotional disorders which will prevent the camper from taking part in all or part of the camping program?*

YesNo

Please specify:

Please list any medications & instructions:

Name of Insured

First NameLast Name

Health Insurance Carrier:

Company:

Group #

Insurance Phone Number

Please enter a valid phone number.

Send Claims to:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Camper*

First NameLast Name

Having been made aware of the activities the camper will be doing. I hereby consent to the camper’s participation in Camp Joy. I voluntarily release and forever discharge CAMP JOY, INC. from any and all liability, claims, actions or rights of action which are in any way related to the camper’s participation at Camp Joy. I agree to indemnify and hold Camp Joy Inc. harmless from any and all costs or damages, including attorney fees, incurred in connection with the camper’s participation in the camping program.

In case of emergency, I understand that every effort will be made to contact parents or guardians of minor camp participants. However, if parents or guardians cannot be reached, or if I, the below signed camper am 18 years of age or older, I hereby give Camp Joy Inc.’s representative to act on my behalf in seeking and administering medical treatment in the event that such treatment is deemed necessary or advisable for the camper’s health, safety and welfare. I release Camp Joy Inc. from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from the camper’s participation in camp activities.

Select the on that applies*

I am the Parent / GuardianI am 18 or older.

By typing my name below, I acknowledge and agree that it serves as my electronic signature, having the same force and effect as a handwritten signature.

Parent / Guardian

First NameLast Name

Submitter email

example@example.com

Signature

Camp Joy Medical Form

Emergency Contact Information

Camper's Health History

Health Insurance Information

Waiver, Release, & Emergency Form