Peace Camp Medical Form
PLEASE USE THE ORANGE FORM we sent you, if possible!
(PLEASE PRINT)
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 2012, June 11- August 24, 2012Please note, Peace Camp staff will do their best to contact you as soon as possible if your child
is sick or injured. In 24 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 # _____________________________
