FORT STEELE SUMMER CAMP FORM
2020 Day Camp
Days Attending Camp
*
July 13th
July 27th
August 17th
July 14th
July 28th
August 18th
July 15th
July 29th
August 19th
July 16th
July 30th
August 20th
July 17th
July 31st
August 21st
July 20th
August 10th
August 24th
July 21st
August 11th
August 25th
July 22nd
August 12th
August 26th
July 23rd
August 13th
August 27th
July 24th
August 14th
August 28th
Child Information
Child Name
*
First Name
Last Name
GENDER
*
MALE
FEMALE
DATE OF BIRTH
*
-
Month
-
Day
Year
Date
CARECARD NUMBER
*
FAMILY PHYSICIAN
DOES YOUR CHILD HAVE ANY ALLERGIES?
*
YES
NO
LIST OF ALLERGIES AND REACTIONS (If Applicable)
DOES YOUR CHILD HAVE ANY OF THE FOLLOWING
ADHD
ASD
Developmental Delays
MEDICATION BEING TAKEN
CAN WE USE PHOTOS ON YOUR CHILD IN OUR MARKETING?
*
YES
NO
PARENT/GUARDIAN INFORMATION
PARENT/GUARDIAN NAME
*
First Name
Last Name
PARENT/GUARDIAN PHONE NUMBER
*
-
Area Code
Phone Number
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMAIL
*
example@example.com
EMERGENCY CONTACT
EMERGENCY CONTACT NAME
*
First Name
Last Name
RELATIONSHIP TO CAMPER
*
MOTHER
FATHER
GRANDPARENT
FAMILY MEMBER
FAMILY FRIEND
OTHER
EMERGENCY CONTACT NUMBER
*
-
Area Code
Phone Number
I AGREE THAT THE ABOVE INFORMATION IS TRUE
Clear
TODAY'S DATE
-
Day
-
Month
Year
Date
Submit
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