Emergency Contact form – Camp Exsighting Adventures

Name

First

Last

Date of birth (mm/dd/yyyy):

Preferred Name

Gender Identity:

Age:

grade in school:

Parent/guardian Name

First

Last

Street address:

City:

State:

Zip code:

Phone number:

Email

Emergency Contact Name

First

Last

Relationship to camper:

Phone Number:

Age: of deemed

Alternate phone Number:

Insurance provider:

Policy number:

Group number:

Please check any of the following medications which may be given to your camper if deemed necessary

Parent/guardian signature:

date signed (mm/dd/yyyy):