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Youth Camp Health History Form

Camper

By completing this Health History Form you are providing all necessary information for Capital SUP to host your child at "Grom Camp" for the 2021 season

Please select who will be participating...
AdultMinor
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First Child's Name

First Name*

Last Name*

Phone*
First Child's Date of Birth*
I certify that I am 18 years of age or older
First Child's Information

Current Residence: *
First Child's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact Information

Emergency Contact #1 (Parent or Legal Gaurdian) : Name & Phone Number *

Emergency Contact #2 (Other than Parent Above) : Name & Phone Number *

Primary Care Physician or other provider of medical care : Name & Phone Number *
Health Information

Are there any health problems including physical, psychiatric, or behavioral problems of which we need to be aware?
No
YES, Please Explain Above

Are there any medications, dietary restrictions, allergies, or special needs that we need to be aware of to ensure that your child's camp experience is positive?
No
YES, Please Explain Above (If your child has medication you will also need to fill out an additional Medication Administration Authorization Form - fill out and email to Kevin@capitalsup.com)
IMMUNIZATION INFORMATION

For campers who currently reside within the United States, a United States territory, or the District of Columbia: Does the camper have any immunization exemptions because of a parental or guardian objection or medical contraindication?
No
YES, Please List Above
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Current Residence: *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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