First and Last Name of Parent or Guardian #1 *

First Name

Last Name

First and Last Name of Parent or Guardian #2

First Name

Last Name

Primary Emergency Phone Number *

(###)

###

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Secondary Emergency Phone Number *

(###)

###

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

First and Last Name of Child *

First Name

Last Name

Birthdate *

MM

DD

YYYY

What grade will the child be in Fall 2025? *

Preschool

Kindergarten

First Grade

Second Grade

Third Grade

Fourth Grade

Fifth Grade

Sixth Grade

Seventh Grade

Eighth Grade

Ninth Grade

Tenth Grade

Eleventh Grade

Twelfth Grade

What gender is your child? *

Male

Female

Date of Last Health Examination *

Must be within the the past 24 months

MM

DD

YYYY

Check all over the counter medications that may NOT be given to your child if they should need medication while at camp. *

Acetaminophen (Tylenol)

Ibuprofen (Motrin, Advil)

Throat Lozenges

Antihistamine (Benadryl)

Antibiotic Ointment (Neosporin)

Antacid (Tums)

Hydrocortisone Cream

Bug Spray (containing Deet)

Antifungal Ointment (for athlete's foot)

Sunscreen

Anti-itch Lotion (Calamine)

None - my child can take all of the above

Is your child restricted or limited from participating in any physical activity? *

Yes

No

Does your child have any of the following health conditions? *

ADHD

Asthma

Diabetes

Headaches/Migraines

Seizures

None

Does your child have any of the following diet restrictions? *

Lactose Intolerant

Vegetarian

Gluten Free

Peanut/Tree Nut Allergy

Other - we will contact you regarding the allergy

None

First and Last Name of Emergency Contact *

Non parent or guardian

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

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