Rainbow Trail Lutheran Camp

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #1 *

First Name

Last Name

Preferred Phone *

(###)

###

####

Parent/Guardian #2

First Name

Last Name

Phone

(###)

###

####

Phone *

(###)

###

####

Do you carry medical insurance? *

Yes

No

Please check and date any of the following, which have occurred to the camper or in the camper’s family (Conditions, Diseases, Allergies,

Frequent ear infections

Heart disease/defect

Convulsions/seizures

Diabetes

Bleeding/clotting disorders

Hypertension

Mononucleosis

Chicken Pox

Measles

German Measles

Mumps

Asthma

Hay Fever

Ivy poisoning etc

Insect Stings

Pencillin

Other Drugs

Psychiatric counseling

*Other- please explain below

Will your child need to take a medication during Day Camp? *

Yes

No