Camper Information Form
(parent or legal Guardian)
Emergency Contact 2
(Other than above)
Primary Care Physician or other medical provider
Are there any Health Problems including Physical, Psychiatric, or Behavioral problems of
which we need to be aware?
Are there any medications, dietary restrictions, allergies or special needs that we need to be aware of?
Must list current residence above.
For campers who currently reside within the United States, a United States territory, or the
District of Columbia: Does the camper have any Immunization exemptions because of a Parental or Guardian objection or Medical contraindiction?
Please answer Yes or No.
(If yes please list)
**for campers who reside outside the United States, a United States Territory, or the District of Columbia
a Record of vaccination or immunity on Departmentform MDH-896