ERC Youth Emergency/Health Form

Camper Information

Name*

First Last

Address*

Street Address City State ZIP Code

Date of Birth*

MM

DD

YYYY

Grade this Fall*

Home Phone

Cell Phone

Email*

Staying on the Grounds:*

Contact Information

1. Parent/Guardian*

Address*

Street Address City State ZIP Code

Cell Phone*

Work Phone*

Staying on the Grounds:*

2. Emergency Contact*

Address*

Street Address City State ZIP Code

Staying on the Grounds:*

Health Insurance Information

All health information must be filled out if guardian is not staying on the grounds

Insurance Company Name*

Policyholder's Name*

Effective Date of Policy*

Policy Number*

Group Number*

Policy Holder's Employer (if group policy)

Health Information

Allergic To

Reactions

Camper is subject to

ear infections
diabetes
asthma

Medications (all medications must be given to the nurse)*

Special Needs or Limitations*

I give consent for routine, non-surgical, emergency medical treatment of my child. I am aware that it will be notified immediately in the event that my child needs to be seen by a doctor.

Eletronic Parent/Guardian's Signature*

I understand by typing my full name above that it constitutes a legal signature confirming that I acknowledge and agree to the terms above.

Date*

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Name

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2024 - ERC Youth Emergency/Health Form

Camper Information

Contact Information

Health Insurance Information

Health Information