Summer Camp Camper Medical Information Form

Camper Name
Date of Birth
Age
Parent/Guardian Name
Contact Phone
Emergency Contact Name
Emergency Contact Phone

Medical Information

Health Insurance Provider
Policy Number
Primary Physician Name
Physician Phone
Allergies (Food, Medication, etc.)
Medical Conditions (Asthma, Diabetes, etc.)
Medications (Name & Dosage)
Dietary Restrictions

Permissions & Agreements

Permission for Emergency Medical Treatment
Other Notes or Instructions
Parent/Guardian Signature
Date