KIDS for the BAY 2013 Summer Camp Emergency Medical Form

KIDS for the BAY 2013 Summer Camp
Emergency Medical Form
Camper’s Name:_______________________________________________ Sex: M F
Camp Session(s) Dates:___________________________
Age (by first day of camp): _________
Physician:_____________________________________________ Phone: ___________________
Health Insurance Provider:______________________________ Policy #:____________________
Any medical information we should know about? (allergies, medications, emotional needs,
special needs) ____________________________________________________________________
_________________________________________________________________________________
Is your child able to swim, at least to keep his/her head above water? (circle one) YES / NO
Additional Information: _____________________________________________________________
In case of emergency or if we need to reach a parent/guardian, best phone # to call during:
Camp hours: Name (Relation) ____________________________ Phone: ____________________
Alternate Phone: ____________________
Evening hours: Name (Relation) __________________________ Phone: ___________________
Alternate Phone: ____________________
Parent/ Guardian’s Information
Name:
Address:
Parent/ Guardian’s Information
Name:
Address: Same
Best Phone #:
Alt Phone #:
Email: __________________________________
Best Phone #:
Alt Phone #:
Email: ______________________________
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(Emergency Medical Form continued on back)
Is anyone else allowed to pick your child up from camp? List the full name(s) of
anyone allowed to pick your child up from camp: (Note: the person who signs your
child in each morning will need to note who is picking your child up if it is someone
different.)
Full Name
Relation to Camper
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Thank you for taking the time to complete this form.
Please put it in the provided stamped, self-addressed envelope and return it
with the Informed Consent and Waiver Form to KIDS for the BAY no
later than June 3, 2013.
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