Peace Camp Medical Form  
PLEASE USE THE ORANGE FORM we sent you, if possible!

Child's Name: ________________________________ prefers to be called: _________________________

Birthdate: _____________ Age: ____Sex: ___ Grade in the Fall: _____ 

School in Fall: _____________________  Child's summer phone number ___________________________ 

Child's summer address __________________________________________________________________

Parent Name: _____________________________________ phone (home): ___________________

                     phone (work): __________________________ phone (cell):    ___________________

Other Parent: _____________________________________ phone (home): ____________________

                     phone (work): __________________________ phone (cell):    ___________________

Parent email address____________________________________________________________________

Child's Health Insurance: ________________________________________________________________
                                            (Company, policy number)

Child's Physician: __________________________________ phone _________________________

In case of a medical emergency, I authorize Peace Camp staff to obtain emergency medical
treatment for my child.  If my child does not have health insurance, I agree to pay all the costs.

                               Parent signature: _________________________________________________
                              Dates of this authorization: Summer 2021: August 3-7 2021
Please note, Peace Camp staff will do their best to contact you as soon as possible if your child
is sick or injured. In 25 years of operation, we have not had to take a child to the emergency room.

medications: _____________________________________________________________________
Please discuss medications with us if your child must take them at camp.

allergies: ________________________________________________________________________

special needs? ___________________________________________________________________
Please discuss your child's special needs with us.

If an emergency occurs, Peace Camp staff will contact the parents first and then call these
 daytime numbers: Please list relatives, family friends, or neighbors who know your child.

1) Name __________________________________________________

 relationship to child ________________________ phone # _____________________________

2) Name __________________________________________________

relationship to child ________________________ phone # __________________________