Minors’ Camp Health Information Release Form
Camper Information
Full Name
Date of Birth
Address
City
State
Zip
Parent/Guardian Information
Parent/Guardian Name
Phone
Email
Emergency Contact
Name
Phone
Relationship
Health Information
Allergies
Current Medications
Medical Conditions/Restrictions
Physician Name
Physician Phone
Health Insurance Provider
Policy Number
Authorization
I authorize the camp staff to obtain medical care for my child in case of emergency. I also consent to the release of the above health information to camp medical staff and relevant personnel.
Parent/Guardian Signature
Date