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*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
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.
Date Date of most recent Tetanus Toxoid Immunization was ____________________________________________________
Do you have health/accident insurance? (check one)*

YESNO
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?*

YESNO
If yes, please explain:
Is camper currently taking medication that may interfere with ability to safely participate in this program?*

YESNO
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?*

YESNO
If yes, please explain:
Does camper have a history of, or currently suffer from, medical condition (s) with which we need to be aware?*

YESNO
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

EARLY BIRD REGISTRATION FLASH SALE (2/4 -2/18)

$35.00 Quantity

Tour

$ Free Quantity

Total

$0.00

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:

Credit Card