Camp Kanesatake 2012 Summer Camp Registration

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Medical Information

Is this camper in general good health and able to participate in all normal camp activities? Please Select... Yes No

If no, please submit a statement indicating limitations.

Please check off if any of these apply and explain in comments section.

Others / Comments

Please list any drug or food allergies that would affect the camper at camp:

Please indicate the date of your child's last tetanus booster:

Current tetanus shots/boosters are required. (Booster shot due every 10 years)

Please list the most recent physical examination date:

Name & Phone Number of Primary Care Physician:

Insurance Co.

Policy #

Consent Required

I have read and agree to comply with the conduct and modesty regulations while at camp.

Initials of Camper

By submitting this form, I certify that I am the parent or guardian of the above named child. In case of medical emergency, I understand that every effort will be made to contact the parent or guardian of the camper named above. In the event that I cannot be reached, I hereby give per mission to the physician selected by the camp leaders to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child as named herein. I understand that Camp Kanesatake does not carry medical or accidental insurance for the camper participants, and I hereby certify that my child, named above, is covered by a personal insurance policy or is included in a policy which is in force. Further, I hereby authorize routine medical dispensary care for the above named camper and authorize treatment not considered routine to be referred to local physicians and medical facilities at my expense. In signing this registration, I hereby certify that all information is correct and I give permission for the use of photographs, audio, and video footage including my child in camp publicity, for my child to be transported in camp operated vehicles for approved out-of-camp activities and for purposes of medical transport, and for the release of medical records in case of illness.

Name of Parent Submitting Form

Email of Parent Submitting Form

After clicking submit, if you do not see a confirmation screen within 5 seconds, scroll up the page and look for any items that were missed and have been highlighted in red. Please complete these items and then click Submit again. Thank you.