Teen Leadership Paddle Health Form
Please complete the following information:

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Student's first & last name *
Please provide student's first name or preferred name
Gender *
Grade entering in fall 2022 *
Birthday *
MM
/
DD
/
YYYY
Home address *
Home phone *
Parent/guardian 1 *
Please provide first and last name
Daytime phone - parent/guardian 1 *
Parent/guardian 2
Please provide first and last name
Daytime phone - parent/guardian 2
Emergency contact *
Emergency contact relationship to student *
Emergency contact phone *
Student's Primary Medical Care Provider *
Doctor's phone *
Date of student's last tetanus shot *
Is your student enrolled in Maryland public schools system? *
If not enrolled in MD public schools, please list dates of immunizations
COVID-19 vaccination status *
Allergies or medical requirements* *
ie. bee stings, penicillin, ADHA medication, dietatary restrictions
During each session, campers will hike, canoe, and camp out. Does your child have any special emotional or physical needs that would affect his/her participation in any camp activities?* *
*special accommodations will be arranged. Please contact Samina Soin-Voshell (samina.soin-voshell@maryland.gov).
Has your child ever attended an overnight camping trip without their parents? *
Parent/guardian signature *
By writing your name in the space below it will act as your electronic signature
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