Name of Class or Workshop

Name of Student

Date of Birth

Age

Address

Phone Number

Email address

Guardian’s Name

Guardian's Primary Phone Number

Guardian's Secondary Phone Number

Guardian's Address (if different from above)

Emergency Contact other than Guardian

Emergency Contact Phone Number

Child's Health Card Number

Child's Doctor's Name

Child's Doctor's Phone Number

Your child’s health and safety are our first concern, existing allergies, medical conditions, medications coming to camp or special needs must be disclosed prior to the start of camp. Your child’s health and safety are our first concern, existing allergies, medical conditions, medications coming to camp or special needs must be disclosed prior to the start of camp.

Existing Medical Conditions/Special needs (please be specific)

Allergies Allergies Yes No

If Yes, please specify

Diabetes Diabetes Yes No

Incontinence Incontinence Yes No

Heart Disease/or other ongoing serious condition Heart Disease/or other ongoing serious condition Yes No

If Yes, please specify

Please list any medications or devices your child may require to have with them at camp