Camp Pride Korea 2019 Medical Information
RequiredRequired Question(s)
Required 1.

Child(ren)'s Name(s)

 

350 characters left.
Required 2.

Family Name

 

50 characters left.
Required 3.

Is Parent Volunteering at Camp?

Yes, Parent is volunteering at Camp.
Parent is not volunteering at Camp. Enter contact information below (include best phone number(s) to reach you.
  • Comment:

  • 500 characters left.
Required 4.

Physician's Name and Contact Information

 

350 characters left.
Required 5.

Insurance Company:

 

50 characters left.
Required 6.

Insurance Policy Number: 

 

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Required 7.

Known Allergies (if none, enter N/A)

 

350 characters left.
Required 8.

Significant Medical History (if none, enter N/A):

 

350 characters left.
9.

Daily Medications Required (Parent must be available during Camp to administer medication to their child).

 

50 characters left.
Required 10.
Date of Last Tetanus immunization:
 

50 characters left.
Required 11.

In case of an emergency and a parent cannot be reached, please provide an alternative contact.


**Include Name, Relationship and Phone Number **

 

350 characters left.
Required 12.

In the event of an emergency, I consent to my child receiving such medical treatment as deemed necessary by the examining physician.


Please provide your name, relationship and address in the comments section.

Yes, I consent.
No, I do not consent.
  • Comment:

  • 500 characters left.
13.

In the interest of offering your child the best possible camp experience, please share any additional needs or concerns below.

 

350 characters left.