The completion of this form is a prerequisite for registration and participation in any 317 Main Summer Camp.

Is the camper currently under a physician’s care or taking any prescription medication(s)?
yesno

If YES, list name of condition(s)/prescription(s):

Is the camper allergic to any medication(s)?
yesno

If YES, please list:

Please note any physical conditions the camper has that may require medical attention
(allergies, diabetes, seizures, contact lenses, etc.):

Insurance information

Name of Company:

Group #:

Policy #:

Address of Company:

Custodial Parent/Legal Guardian: