Pleasant Bay Camp :: Staff/LIT Health Form

General Information

*	First Name:
*	Last Name:
*	Address:
*	City:
*	State/Province:
*	Zip/Postal Code:
*	Email Address:
*	Please enter your birthday in the order of month/day/year.
*	Please write your health number.
	Please write any other type of health insurance and the corresponding number and info.
*	Please write the name of your family doctor and phone number.
*	In the case of emergency please list the contact name, number(s) and relationship to you.
*	If this person is unavailable who should we contact?
* Will medication be required at camp?
	If yes please list the name of the medication and give dosing instructions. Please ensure that medication is handed into the nurse and is in its original container.
	Do you suffer from any condition or illness that will affect your time at PBC? Please explain.
	Do you have any allergies? Please describe.
	Do you require a special diet while at camp. For example, no dairy or vegetarian.
	Are your immunizations up to date?
	Is there any other medical information that you think we should know?
* By submitting this form you realize that PBC will act on your behalf in the case of an emergency.
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