Camper Name:

   

Birthday:

(mm/dd/yyyy)     Age:    Sex:

School

   Grade (next fall):    # of Siblings:

Parent/Guardian Name:

    Home Phone:

Address:

City:

State: Zip:

Work Phone Mother:

   Work Phone Father:

Cell Phone Mother:

   Cell Phone Father:

Email Mother:

   Email Father:

Telephone numbers where parents can be reached during backpacking,
if different than above:

Is camper a swimmer?

Yes   No         Date of last Tetanus shot: (mm/dd/yyyy)

Physician:

   Physician Phone:

Insurance Company:

Group Number:

   Customer Number:

May your child ride horseback?  Yes   No

Do you have any dietary restrictions (vegetarian, etc.)?

Can we use pictures of your child in future brochures and advertising?     Yes   No

Are there other things we should know? Please explain any further information about physical or behavioral conditions that the camp staff should know about, such as sleepwalking, bedwetting (please send an easily laundered sleeping bag), epilepsy, fainting, asthma, hyperactivity, nose bleeds, etc. Please be as specific as possible:

Is there any additional information, which would be of help in promoting your child's welfare at camp? Please include any experiences that might be upsetting to your child:

As-Needed Medications
If you do not wish to have your child treated using the following medications in the event
of the presence of the symptoms indicated, please check the "No" column.

Abdominal Pain

Maalox

Nausea

Kaopectate or Homeopathic Remedies

Allergy, Hives, Bites

Hydrocortisone Cream 1% or Benadryl Cream

Constipation

Milk of Magnesia

Cough

Robitussin DM

Cuts

Hydrogen Peroxide and Neosporin Cream

Diarrhea

Kaopectate or Imodium

Earache

Acetaminophen or Homeopathic earache tablets

Eye Irritation

Visine AC

Fever, Flu: Headache

Acetaminophen, Ibuprophin or Homeopathic Remedies

Menstrual Cramps

Acetaminophen or Ibuprophin

Rash

Cortaid Cream

Sore Throat

Warm Salt Gargle, Acetaminophen, Echinacea Spray or Homeopathic Remedies

Sunburn

Calendula Cream

Bruises, Sore Muscles

Arnica Cream and Homeopathic Tablets