Medical Release and Emergency Contact Form

Contact Information

Student Name: *
Student Birthdate: *
Parent/Guardian Name: *
Parent/Guardian Address: *
Parent/Guardian E-mail: *
Parent/Guardian Cell Phone: *
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Medical Information


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:

Emergency Contact Information


Pediatrician Name: *
Pediatrician Phone: *
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Pediatrician Address: *
Emergency Contact #1 Name:
Emergency Contact #1 Number:
Contact #1 Relationship to Camper:
Emergency Contact #2 Name:
Emergency Contact #2 Number:
Contact #2 Relationship to Camper:
Word Verification: