Medical Release and Emergency Contact Form

Student Name*
Student Birthdate*
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Parent/Guardian Name*
Parent/Guardian Address*
Parent/Guardian Email:*
Does the student have any medical conditions or allergies? *
If there are medical conditions or allergies, please list:
Does the student have any behavioral, emotional or developmental issues? *
If the student has any of the above identified issues, please list:
Pediatrician Name*
Pediatrician Phone*
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Pediatrician Address*
Emergency Contact #1 Name:
Emergency Contact #1 Number:
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Contact #1 Relationship to Camper:
Emergency Contact #2 Name:
Emergency Contact #2 Number:
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Contact #2 Relationship to Camper: