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Medical Form

We’re excited to have your child join us for an unforgettable camp experience! To help us ensure the safety and well-being of every camper, we ask that you please complete this medical form. This will provide us with important health information and allow us to best support your child’s needs during their time at camp.

Please complete one form for each child. If you have any questions or need assistance, feel free to reach out to our team. Thank you for helping us make Discover Camp a safe and fun place for all campers!

Camper Information

Camper's First Name:
Camper's Last Name:
Street Address:
City:
State:
Zip Code:
Camper's Age:
School:

Camper's Date of Birth

Sex

Female Male

Please upload a recent picture of your child. This helps us with camper identification and assists our staff in getting to know them better.

Maximum size: 2MB.

Only the following filetypes are allowed: png, gif, jpg, jpeg

Please upload at most one file

Upload file

	Title	Comment	File name

CareGiver Information

The Child's Primary Caregiver Name:
Relationship to Child:
Cell Phone:

Emergency Contact Numbers

I authorize the following person(s) or agency to be contacted in the event of an emergency and I cannot be reached. I also authorize the following person(s) or agency to be contacted and authorize my child to be turned over to this person(s) if for any reason my child must leave camp or be picked-up if I am unavailable.

Name:
Relationship:
Home Phone:
Cell Phone:

Second Emergency Contact

Name:
Relationship:
Cell Phone:

Insurance Information

Insurance Provider Name:
Insurance Provider Card Number:
Insurance Provider Phone Number:

Insurance Information - Front of Card

Please take a picture of the front of your card and upload it here. Please set your camera's image quality to "Medium" or it may be too big to upload. Please be sure that the image can be easily read by us.

Maximum size: 2MB.

Only the following filetypes are allowed: png, gif, jpg, jpeg

Please upload at most one file

Upload file

	Title	Comment	File name

Insurance Information: Back of Card

Please take a picture of the back of your card and upload it here. Please set your camera's image quality to "Medium" or it may be too big to upload. Please be sure that the image can be easily read by us.

Maximum size: 2MB.

Only the following filetypes are allowed: png, gif, jpg, jpeg

Please upload at most one file

Upload file

	Title	Comment	File name

Medical Information and History

Please list any current problem(s): Please list any current problem(s):
Please list any current medical conditions:
List any medications taken for behavior:
List any other medications taken:

Medical Conditions

Please check all that apply. List in the comments anything you would like us to know about the condition.

Comment only when you choose an answer.

Bleeding/Clotting Disorders:
Diabetes:
Bee Sting Allergy:
Heart Disease:
Heart Defects/Murmur:
Seizures:
Chronic Pain:
Asthma:
Allergies (Medication or Food list in comments):

Immunizations

Please upload your child's most recent immunization record below. Please make sure it is easily readable by us.

Maximum size: 2MB.

Only the following filetypes are allowed: png, gif, jpg, jpeg

Please upload at most one file

Upload file

	Title	Comment	File name

Immunizations

Please upload any additional pages here, if necessary.

Maximum size: 2MB.

Only the following filetypes are allowed: png, gif, jpg, jpeg

Please upload at most one file

Upload file

	Title	Comment	File name

Immunizations

Please upload any additional pages here if necessary.

Maximum size: 2MB.

Only the following filetypes are allowed: png, gif, jpg, jpeg

Please upload at most one file

Upload file

	Title	Comment	File name

Additional Information

Please add any other information you feel we should know about your child.

Confirmation

I certify that all information I have provided is accurate.

Please confirm you want to clear your response?