CSBC

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2020 CSBC Summer Camp

Emergency Contact & Medical Information Form

CONTACT INFORMATION

Parent First Name:

Parent Last Name:

Mobile Number:

Email:

Address:

City:

State:

Zip:

Child's First Name:

Child's Last Name:

Child Lives With:

Name of camp(s) attending:

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EMERGENCY CONTACT INFORMATION

First Name:

Last Name:

Phone #:

Relationship:

In the event of an EARLY DISSMISSAL OR EMERGENCY, my child should:

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Person #1 Authorized to Pick-Up - Name/Relationship:

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Person #1 Authorized to Pick-Up - Address / Phone:

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Person #2 Authorized to Pick-Up - Name/Relationship:

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Person #2 Authorized to Pick-Up - Address / Phone:

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Person #3 Authorized to Pick-Up - Name/Relationship:

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Person #3 Authorized to Pick-Up - Address/Phone:

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MEDICAL INFORMATION

I will apply sunscreen to my child before sending him to camp (Super Saints, STEAM Camp and Sports Camps)

I give permission to take my child's temperature upon arrival at camp.

Does your child have any allergies (food, medication, environment, insects, etc.)?

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Any medical conditions that summer camp staff should be aware of (asthma, heart murmur, seizures, eye/vision, hearing, etc.)?

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Any other information that you feel is important for the Summer Camp Staff to know:

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CONTACT INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

Donation amount