Camper Information Form
Emergency Contact
(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?

Immunization Information

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

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15221 Display Court

Rockville  MD  20850

 

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Rockville Fencing Academy

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