Medical Release and Emergency Contact Form

Contact Information

Student Name: *


Title	First	Last	Nickname

Student Birthdate: *

Parent/Guardian Name: *


First	Last

Parent/Guardian Address: *

Street AddressCityState / Province / RegionPostal / Zip CodeCountry

Parent/Guardian E-mail: *

Parent/Guardian Cell Phone: *

-
Area Code	Phone Number

Does the student have any medical conditions or allergies?: *

If there are medical conditions or allergies, please list:

Does the student have any behavior,emotional or developmental issues? *

If the student has any of the above identified issues, please list:

Pediatrician Name: *


First	Last

Pediatrician Phone: *

-
Area Code	Phone Number

Pediatrician Address: *

Street AddressCityState / Province / RegionPostal / Zip Code

Emergency Contact #1 Name:


First	Last

Emergency Contact #1 Number:

Contact #1 Relationship to Camper:

Emergency Contact #2 Name:


First	Last

Emergency Contact #2 Number:

Contact #2 Relationship to Camper:

Word Verification: