Privacy notice: This information is needed to alert camp administration of the medical needs of the camp population. It will be treated as confidential medical information, and will be given to appropriate medical service providers in case of an emergency. Failure to provide this information will result in the camper not being allowed to attend camp. Name* First Last Birthdate* MM slash DD slash YYYY Age*Biological Sex* Male Female Gender* Male Female Parent/Guardian 1 Name* First Last Parent/Guardian 2 Name First Last Home Phone*Alternate Telephone #(cell, work, etc.)Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Health Insurance Company* Policy Number* Emergency Contact Name (If Parent/Guardians not available)* First Last Emergency Contact Phone*Continuing Conditions* Asthma Diabetes Sleepwalking Chronic pain Bedwetting Gastro-intestinal issues Other(s) None Describe Other Condition(s)Does your child have any restrictions on their diet? If yes, please explain.*Does your child have any allergies? If yes, please list all allergies.*Does the camper have any social or developmental diagnoses? If yes, please explain.Are there any restrictions/limitations on your child's activities? Please explain and provide ideas about how we might help with these.Medications to be taken at camp (Name/Dosage (if any))Please include Over the Counter and Prescription medications and be sure to obtain your doctor's signature for all on Physician Approval for Medication at Camp form.Has your child received 2 doses of the Measles (usually MMR) vaccine?*SelectYesNoHas your child been fully vaccinated against Covid-19?*SelectYesNoDo you give permission for your child to carry and use insect repellent at camp?*SelectYesNoDo you give permission for your child to carry and use sunscreen at camp?*SelectYesNoComplete only if your child is attending Overnight Camp (New York State Public Health Law Requirement.) My child has had meningococcal meningitis immunization within the past 10 years. [Note: If your child received the meningococcal vaccine available before February 2005 called Menomune™, please note this vaccine’s protection lasts for approximately 3 to 5 years. Revaccination with the new conjugate vaccine called Menactra™ should be considered within 3-5 years after receiving Menomune™.] I have read, or have had explained to me, the information regarding meningococcal meningitis disease. I understand the risks of not receiving the vaccine. I have decided that my child will not obtain immunization against meningococcal meningitis disease. Date of Meningitis vaccine MM slash DD slash YYYY Please provide medications in their ORIGINAL CONTAINERS with the actual prescription, plus a signed doctor's note, and instructions attached. Please include situational medications such as inhalers and epi-pens in this list as well. Please print and provide your doctor with our Physician Approval for Medications at Camp form if needed.Additional comments/ concerns:Signature*HiddenHealth form printed No Yes Health form printed
