CE NC CityChangers #1

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.
YesNo
YesNo

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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