Peacemakers' Day Camp

Full Name of Participant:

Email:

Special Medical Needs:

Allergies:

Food sensitivities or limitations:

History of any medical conditions we should know:

Any other limitations:

Childhood diseases or injuries, with dates:

Special behavioral/psychological facts we need to know:

Has your child recieved an updated immunization for:

Tetanus:
yes no
Chicken Pox:
yes no
Diphtheria:
yes no
MMR:
yes no
Polio:
yes no
Hepatitis:
yes no
Influenza:
yes no
Other (What type?):

Doctor's Name:

Medical Facility Caring for Child:

Address and Phone Number:

Insurance Information: