Smunchkin' Health Form

Dear Parents/Guardians of Smunchkin' Campers,
Thanks for taking the time to fill out this form so our nurse (and food services) can serve you better!

Health Form

* Indicates required field

Smunchkin' Name *

First

Last

Date of Birth (Month/Day/Year) *

Birth Sex *

Male Female

Home address

Parent Contact Phone Number *

full mailing address *

Emergency contact information

Emergency Contact #1 *

First

Last

Phone Number *

Allergies

Dietary (please type "none" if no restrictions) *

Allergies (please type "none" if no allergies) *

Anaphylactic Allergic Reaction? *

Anything else the staff should know regarding your allergies? *

General Medical Information

Health Information - Please let us know what the BYC staff be aware of? *

List medications *

Other information *

Medical /Photo Release/ Digital Signature

I consent to medical attention by the BYC staff and should it be necessary other health care providers. By typing my name below I give medical as well as permission to be photographed for camp materials. *

Date *

Submit

Health Form

Home address

Emergency contact information

Allergies

General Medical Information

Medical /Photo Release/ Digital Signature

Mailing address
PO Box 1214, Ellsworth, ME 04605
located in Charlotte Maine

Serve

Health Form

Home address

​Emergency contact information

Allergies

General Medical Information

Medical /Photo Release/ Digital Signature

Mailing address​PO Box 1214, Ellsworth, ME 04605located in Charlotte Maine

Serve

Emergency contact information

Mailing address
PO Box 1214, Ellsworth, ME 04605
located in Charlotte Maine