Camp/Clinic Name

EMERGENCY INFORMATION

Full Name of Minor_______________________________________________________                                                  
Date of Birth of Minor_____________________________________________________ 
Home Address____________________________________________________________ 
Home Telephone Number___________________________________________________                                         
Person to Call in Case of Emergency__________________________________________
Relationship to Minor______________________________________________________
Telephone # of Contact Person_______________________________________________
Alternate Contact Person___________________________________________________
Telephone # of Alternate Contact_____________________________________________

Physician's Full Name______________________________________________________                                                
Address_________________________________________________________________
Physician's Telephone #____________________________________________________
Name of Family Medical Insurance Policy_____________________________________	
Policy Number___________________________________________________________
Name & Social Security # of Policy Holder____________________________________ Insurance Address_________________________________________________________
Is a referral required from your Physician for an emergency?_______________________

Describe in full, any allergies – drug, food, insect bites, etc. (Attach additional sheet if needed.)_________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________

6/5/07