Name of Camper:______________________________________________________________

Address:____________________________________________________________________

___________________________________________________________________________

Age:_____________ Birth Date:___________________Height_________ Weight_________

Allergies:_____________________________________________________________________

Handicaps:___________________________________________________________________

Food Allergies:________________________________________________________________

Medications:__________________________________________________________________

Mother’s Contact Information:   Name:______________________________________________

Home Phone:_________________ Cell:__________________

Pager:____________________ Office:___________________

Father’s Contact Information:    Name:_______________________________________________

Home Phone:_________________ Cell:__________________

Pager:____________________ Office:___________________

Other Contact: Name______________________________ Number:_____________________

Physician’s Name:_________________________________ Number:_____________________

Dates attending camp:___________________________________________________________

Resident or Day Camper?____________________________