Camp Echo Registration Form

Summer Camp Registration
Part 1. General Information
Name

First NameLast Name
Birth Date

MonthDayYear
Grade
T-Shirt Size ( please emphasize if youth or adult size)
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Please list at least one additional emergency contact.
Part 2. Medical Information
Physicians Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Date of most recent Tetanus Toxoid Immunization was ____________________________________________________
Do you have health/accident insurance? (check one)
If yes, please indicate the policy number, name and address of Insurance Company. (PLEASE PROVIDE A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD WITH THIS FORM)
For the following, check appropriate response and explain as necessary:
Does this camper have any limiting medical conditions that you or your doctor feel would limit activities?
If yes, please explain:
Is camper currently taking medication that may interfere with ability to safely participate in this program?
If yes, please indicate the medication and condition being treated:
Does camper have a history of allergies or reactions to medications, insect stings, or plants?
If yes, please explain:
Does camper have a history of, or currently suffer from, medical condition (s) with which we need to be aware?
If yes, please explain:
Important Information we should know:
Authorization for Medical Care:

Camper has my permission to receive medical attention in the event of illness or medical emergency while participating in this Program. I will assume the financial responsibility for any cost of health care for my child that may occur during this Program. As a Student, parent, or guardian I understand and acknowledge that my failure to disclose relevant information may result in harm to Student and/or others during this Program. By signing my name, I represent and warrant that I have provided all materials and important information pertaining to my Student’s medical, mental and physical condition and that it is accurate and complete.
Parent/Guardians Name

First NameLast Name
Date

MonthDayYear
Date
Signature

My Products

General Registration

$50.00

Total

Credit Card

Should be Empty:

Summer Camp Registration

Part 1. General Information

Part 2. Medical Information

For the following, check appropriate response and explain as necessary:

Authorization for Medical Care:

My Products

Credit Card