Camp Summerset

Medical & Transportation Form

    CAMP SUMMERSET – MEDICAL AND TRANSPORTATION FORM

    Please be advised that all information on this form will be kept confidential. Answer all the questions, sign, and return with your application.
    Name: Date of Birth:
    Street Address: City:
    State: Zip:
    Phone Number: Email:
    Is your child allergic to ANY foods or medicine?:
    Is your child allergic to BEE STINGS? :
    Does your child take any medication?: (If yes, please provide details)
    Any physical activity he/she cannot participate in? :
    Any other important health related information? :
    Persons AUTHORIZED to pick up my child
    1.
    2.
    3.
    Name & Phone # of Doctor:
    In case of emergency, we can be reached at the following phone numbers:
    1: 2: 3:
    If I CANNOT be reached, call
    Or call
    Parents or Guardian Authorization: In case of emergency, if family physician CANNOT be reached, I hereby authorize my child to be treated by “CERTIFIED EMERGENCY PERSONNEL” (i.e. EMT, first responder, ER Physician)
    Parent Signature: Date: