The completion of this form is a prerequisite for registration and participation in any 317 Main Summer Camp.
Camper's name (required)
Your email (required)
In case of emergency, contact (required)
Relation to camper:
Emergency contact phone
Primary physician’s name:
Is the camper currently under a physician’s care or taking any prescription medication(s)?
If YES, list name of condition(s)/prescription(s):
Is the camper allergic to any medication(s)?
If YES, please list:
Please note any physical conditions the camper has that may require medical attention
(allergies, diabetes, seizures, contact lenses, etc.):
Name of Company:
Address of Company:
Custodial Parent/Legal Guardian: