Medical Release Form

First Name

Last Name

Child First Name

Child Last Name

Emergency Contact Name

Emergency Contact Phone

Family Doctor

Health Insurance Company & Plan Name

Insurance Company Phone

Health Insurance Policy Number

Insurance Group Name or Number

Does your child have any allergies?

Does your child require an Epipen?

Does your child have any dietary restrictions?

Will your child be taking any medications while at camp?

Is there anything the camp needs to be aware of when giving any of the approved over-the-counter medications to your child?

Has your child been exposed to any communicable diseases within the last 3 months?

Does your child have any restrictions on activity?

Will your child require any special assistance while at camp?

Please list any other medical information the camp should have about your child.

Thanks for submitting!