Kids Camp Health Form
Pleasant Bay Kids Camp
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Gender*

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Please indicate whether the camper is covered by any other type of Insurance coverage:*
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Does the camper live at the address listed earlier in this Form?*
Who does the camper live with?*
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Will medication be required at camp?*
Does the camper have any of the following:*
Does the camper have any physical, mental or emotional weakness or disability, chronic condition or recent illness which the staff should be aware of that may require attention?*
Has the camper recently been exposed to an infectious disease?*
Does the camper have any allergies?*
Are the camper's immunizations up to date?*
Does the camper have any restrictions on swimming or any other camp activity?*
By completing and submitting this Form, I am authorizing the Camp Nurse/Camp Director to act on my behalf in an emergency.*
Please indicate which week the camper will be coming.*

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