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Please Complete Medical Information
Online Medical Form
Paper Medical Form
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Paper Medical Form
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Contact Information
Camper Name
First
Last
Sex
Date of Birth
dd/mm/yyyy
Registering Parent Name
First
Last
Registering Parent Email
*
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Home Phone
Cell Phone
Other Parent or Guardian's Name
First
Last
Home Phone
Cell Phone
Emergency Contact Name
Emergency Contact Phone
Doctor's Name
Doctor's Phone
Medical Information
Care Card Medical Number
Are immunizations up-to-date?
Yes
No
Does the child have any limiting health problems?
(e.g. allergies, asthma, epilepsy, diabetes)?
Any other concerns the counselor should know about?
(e.g. bed wetting, sleepwalking, fears)?
Does the child require medication?
Yes
No
If so, will the parent/guardian administer it?
Yes
No
Please detail any special instructions:
Waiver Information
In the event that the camper is injured, ill, or in need of medical attention, and we are unable to be contacted, we authorize Evans Lake Family Camp organizers and volunteers to seek medical attention for the camper on our behalf.
Both parents agree with the above statement
Phone
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