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MYCamp Medical Information Form
Please complete the below information
for EACH child
you have attending MYCamp.
"N/A" is an acceptable response in instances that don't apply to your child.
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* Indicates required question
Email
*
Your email
Camper's Name
*
Your answer
Dietary Requirements (vegetarian, gluten-free, food allergies, etc)
*
Your answer
Medical Conditions (physical limitations, non-food allergies, etc.)
*
Your answer
Learning Exceptionalities (ADHD, spectrum, gifted, etc.)
*
Your answer
Do any of the above dietary requirements, medical conditions, and/or learning exceptionalities require special attention/understanding from MYCamp staff? If yes, please summarize below & contact MYC directly to create advance plans.
*
Your answer
Family Physician Name & Phone
*
Your answer
Does your child have medical insurance?
*
Yes
No
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