Parent-Provided Information for Student Dietary/Medical Needs

Dear Parent,

Help us better serve your child by completing this form. You will have an opportunity to note any dietary concerns, medical needs, etc. You may also include any specific emotional or behavioral concerns that you would like our staff to be aware of. All information is voluntary but dietary concerns are required for meal preparation and planning. We will also work with your church leaders to ensure we are equipped to work with, serve and care for your child while they are with us at JP.

A note on dietary needs: In 2024, our kitchen staff will be preparing meals for 100 people two times each day. To be the best stewards of time and resources, it is extremely important for the staff to have accurate information on the serious issues our campers deal with. So please do not use this form for preferences or dislikes. Thank you!

Dates attending the Jeremiah Project:*

Parent's Name

First NameLast Name

Name of Child*

First NameLast Name

Email*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Church Name*

Spelled out completely (no abbreviations)

What grade will your child have completed in June 2023?*

Male or Female*

MaleFemale

Please list any Dietary Concerns such as: food allergies, food intolerances, celiac disease, vegetarian etc.

Please note any medical, emotional or behavorial concerns you may wish for our staff to be aware of: