Summer Camp Health & Emergency Contact Form Summer Camp Health and Emergency Contact FormPlease fill in all fields below.Camper Name:(Required) Camper First Name: Camper Middle Name: Camper Last Name: Camper Suffix Camper Date of Birth:(Required) MM slash DD slash YYYY Camper Gender(Required) Male Female Non-binary Agender My gender is not listed Prefer not to answer Camper Race/Ethnicity (select multiple)(Required) American Indian or Alaska Native Asian or Asian American Black or African American Hispanic or Latino/a Middle Eastern or North African Native Hawai`ian or Pacific Islander White or European Prefer not to say My race or ethnicity is not listed Camper race or ethnicity is best described as:If your race or ethnicity is not listed in the above question, please use this text box.Camper's Grade Entering in Fall 2024(Required)Camper Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code County(Required)(i.e. Baltimore City, Baltimore County, Howard County, Anne Arundel County, etc)Parent/Guardian/Emergency Contact #1:(Required) Parent/Guardian/Emergency Contact #1 First Name: Parent/Guardian/Emergency Contact #1 Last Name: Parent/Guardian/Emergency Contact #1 Phone Number(Required)Parent/Guardian/Emergency Contact #1 Email Address(Required) Enter Email Confirm Email Parent/Guardian/Emergency Contact #2:(Required) Parent/Guardian/Emergency Contact #2: First Name: Parent/Guardian/Emergency Contact #2: Last Name: Parent/Guardian/Emergency Contact #2: Phone Number(Required)Parent/Guardian/Emergency Contact #2: Email Address(Required) Enter Email Confirm Email Additional People Authorized to Pick up CampersPlease list name(s) and phone number(s)Health InformationAre there any physical, psychiatric, or behavioral health concerns we need to be aware of?(Required) Yes No If yes, please explain(Required)Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive?(Required) Yes No If yes, please explain(Required)Does the camper require access to medication during the camp day and will be submitting form MDH-4758, "Medication Administration Authorization" form, or "Asthma Action Plan and Medication Administration Authorization Form" for inhalers or other asthma-related medication?(Required) Yes No Immunization InformationDoes your camper currently reside within the United States, a United States territory, or the District of Columbia?(Required) Yes No Does the camper have any immunization exemptions because of a parent or guardian objection or medical contraindication?(Required) Yes No If yes, please list exemptions:(Required)Parent/Legal guardian Signature(Required) As a parent/legal guardian, I confirm that the information above is accurate.Signature(Required) First Last Date(Required) MM slash DD slash YYYY
