Medical Release and Emergency Contact Form

Student Name*

First

Last

Nickname

Student Birthdate*

day

month

year

Parent/Guardian Name*

First

Last

Parent/Guardian Email:*

Parent/Guardian Address*

Street AddressCityState / Province / RegionPostal / Zip Code

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

Yes

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

Does the student have any medical conditions or allergies? *

Yes

If there are medical conditions or allergies, please list:

Pediatrician Name*

Title

First

Last

Pediatrician Phone*

Area Code

Phone Number

Contact #2 Relationship to Camper:

Pediatrician Address*

Street AddressCityState / Province / RegionPostal / Zip Code

Emergency Contact #1 Name:

First

Last

Emergency Contact #1 Number:

Area Code

Phone Number

Contact #1 Relationship to Camper:

Emergency Contact #2 Name:

First

Last

Emergency Contact #2 Number:

Area Code

Phone Number