Participant Information:
Last Name:		First Name:		Date of Birth:
Address:		City:		State:
Zip Code:		Phone Number:		e-Mail:
Emergency Contact 1:		Emergency Contact 1 Number:
Emergency Contact 2:		Emergency Contact 2 Number:
T-Shirt Size:	Small Medium Large X-Large
Parent/Guardian Information:
Last Name:		First Name:		e-Mail:
Phone Number:		Work Number:		Cell Number:
Health Information:
The information you provide here will be held in the strictest confidence. It will be kept on file in our health binder or carried by the camp director when your child travels on the SJSU campus with one of our camp groups.
Child's Doctor's Name:		Phone Number:
Allergies:	Yes No
If yes, please describe the severity of the reaction, requested accommodations and what is done to manage them.
May we serve your child food and beverages:	Yes No
Medical, Physical, or Emotional Conditions (including Disabilities):
If your child does have any conditions, please provide information to assist us in providing the best camp experience for your child.
Medications (including Inhalers):	Yes No
If your child must take medication while at camp, please note here. All medications must be in their original containers and be appropriately labeled. Please do not give your camper's medication to them to bring to camp; medications must be received and held by the camp office or with the camp director.
Is your child up-to-date on all state-required immunizations?	Yes No
Insurance Information:
Is the participant covered by family medial/hospital insurance?	Yes No
Carrier or Plane Name:		Group #:
Address:		City:		State:
Zip:		Name of Insured:		Relation:

 

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