Dream Feather Volleyball Camper Medical Information

Please complete this form as thoroughly as possible. Please print and include any information concerning

your child that would help us serve and accommodate your child as best as we can.

Camper’s Name:____________________________________________________________ (last name) (first name)

Home Address: _____________________________________________________________ (street) (apt)

_____________________________________________________________ (city) (postal code)

Date of Birth: ____/_____/_____ Age:______ Gender: M_____ F_______ D M Y

Parent/Guardians Name: ______________________________________________________ (last name) (first name)

_______________________________________________________ (last name) (first name)

Parent/Guardians Address: same as campers or

____________________________________________________________

(street) (apt)

_____________________________________________________________ (city) (postal code)

Parent/Guardians Phone Numbers :______________________________________________________ (home) (business) (cell)

INCASE OF EMERGENCY (check here if emergency contact is same as above) or

_________________________________________________________________________ (Name) (Relation to the camper)

________________________________________________________________________ (Address) (Telephone Number)

Doctor’s Name: _____________________________ Doctor’s Telephone Number:____________________

Medical/Behavioural:

Does your camper have any health or behavioural conditions that we should b aware of? For example, diabetes, epilepsy or prone

to seizures, heart disease, kidney trouble auditory or visual impairments, emotional concerns, asthma, special physical needs, home

sickness, death in the family, recent separation /divorce etc? Yes No

If yes please elabo-

rate:___________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_______________________________________________________________________________________________________