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Form Instructions

Before you start this form, you are going to need the following information:

The participant's immunization history, preferrably an electronic copy that you can upload to this form.
A copy your insurance card, preferably an electronic copy that you can upload to this form.
Your primary physician's phone number and address.

After you complete the information on line, you will be asked to print, sign, and return the authorization page.

Questions? Email the Executive Director at redoakcamp@redoakcamp.org.

Thanks!

Participant Information

* First Name

* Last Name

* Birth Date

* Age at start of camp

* Male/Female

* Your Camp Is

Please Attach a Picture of Your Camper

Emergency Contact Information

* Participant's Primary Address

Address 2

* City

* State

* Zip

PRIMARY CONTACT INFORMATION

* Primary Contact's Full Name

* Primary Contact's Relationship to Participant

* Phone Number to Call First

* Phone Number to Call Second

* Primary Emergency Email Address

SECONDARY CONTACT INFORMATION

* Secondary Contact's Full Name

* Secondary Contact's Relationship to Participant

Phone Number to Call Third

Phone Number to Call Fourth

* Secondary Emergency Email Address

Permission To Treat

*

By checking the box below, I am certifying that the information about the participant correct and accurate. I give permission to the physician or health professional selected by the camp to order x-rays, routine tests, and treatment related to the health of the participant for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the camp to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

From the ACA Health History Form.

Yes, I agree with the above statement

Insurance

* The participant has medical insurance?

Please provide the following information about the participant's insurance coverage below:

	Type Answer Here
Name of Insurance Company
Policy Number
Subscriber
Insurance Company Phone Number

* Indicates Response Required