Please Complete Medical Information

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Paper Medical Form

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
Name
This field is for validation purposes and should be left unchanged.