Stark Home Builders Camp @ Stark State

Medical Information & Release Form
Camper's Date of Birth

MonthDayYear
Camper's Gender
Camper's Race
Camper's Ethnicity
Please list and describe any medical conditions we should know about.
Current medications/dosages?
Please type "none" or "N/A" if none apply. Any medication needed during camp must be administered by our designated adult and must be in the original container labeled by the pharmacy, including over-the-counter medicine. Please clarify any additional instructions if needed.
Please list any allergies we should know about (food, medical, or environmental).
Please type "none" or "N/A" if none apply
Insurance Provider
Insurance Policy Number
Family Physician's Office
Family Physician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Family Dentist's Office
Family Dentist's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Pick Up Information

At the end of each day of camp, a TomTod team member will accompany campers outside for pickup. To help pickup go smoothly, please answer the following questions.
Is your camper allowed to walk home from camp unaccompanied?
I would like to show a form of ID each day in order for my child to be picked up (parent/guardian or approved adult will need to park car and come to the camp sign to check out with a camp staffer). You will be prompted to list authorized pickup individuals on the next page if you mark "Yes."

Authorized Pick Up Information
Please list names (first and last) of any individuals who may pick up your camper if they show a form of ID. Don't forget to include yourself! If your name is not on this list, you will not be allowed to pick up your camper.

Almost done!
Is there any other information you would like to share about your camper that would be helpful for us to know? Please share below!
Should be Empty:

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