Medical Release and Emergency Contact Form

Medical Release & Emergency Contact

Student Name(Required)

First Last

Student Birthdate(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Email(Required)

Parent/Guardian Cell Phone(Required)

Does the student have any medical conditions or allergies?(Required)

If there are medical conditions or allergies, please list:

Does the student have any behavior, emotional or developmental issues?(Required)

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

Pediatrician Name(Required)

First Last

Pediatrician Phone(Required)

Pediatrician Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact #1 Name

First Last

Emergency Contact #1 Phone

Contact #1 Relationship to Camper

Emergency Contact #2 Name

First Last

Emergency Contact #2Phone

Contact #2 Relationship to Camper