Camp Summerset

Medical & Transportation Form

    CAMP SUMMERSET – MEDICAL AND TRANSPORTATION FORM

    Please be advised that all information on this form will be kept confidential. Answer all the questions, sign, and return with your application.

    Name: Date of Birth:

    Street Address: City:

    State: Zip:

    Phone Number: Email:

    Is your child allergic to ANY foods or medicine?:

    Is your child allergic to BEE STINGS? :

    Does your child take any medication?: (If yes, please provide details)

    Any physical activity he/she cannot participate in? :

    Any other important health related information? :

    Persons AUTHORIZED to pick up my child

    1.

    2.

    3.

    Name & Phone # of Doctor:

    In case of emergency, we can be reached at the following phone numbers:

    1: 2: 3:

    If I CANNOT be reached, call

    Or call

    Parents or Guardian Authorization: In case of emergency, if family physician CANNOT be reached, I hereby authorize my child to be treated by “CERTIFIED EMERGENCY PERSONNEL” (i.e. EMT, first responder, ER Physician)

    Parent Signature: Date: