2023 GreenUP Camper Health & Information Form

Camper & Emergency Contact Information

Please note - A separate form MUST be submitted for each camper attending camp in 2023.

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* 1. Your Email Address

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* 2. Camper's First Name:

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* 3. Preferred Name

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* 4. Camper's Last Name

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* 5. Preferred Pronouns

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* 6. Birthdate (mm/dd/yyyy)

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* 7. Camper’s Age on July 1st 2023

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* 8. Household Street Address:

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* 9. City/Town:

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* 10. Postal/Zip Code

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* 11. Province/State:

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* 12. Cell Phone# (ex. XXX-XXX-XXXX):

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* 13. Home Phone# (ex. XXX-XXX-XXXX):

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* 14. Who has Custody and is Legally Responsible for this camper (be sure to include their contact information below):

Both Parents (live together)

Joint Custody (live apart)

Mother

Father

Grandparents

Guardian

Foster Parents

Other

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* 15. Full Name of First Point of Contact in Case of Emergency (Include Parents/Guardians):

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* 16. Relationship to Camper:

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* 17. Primary Phone # (ex. XXX-XXX-XXXX):

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* 18. Work Phone # (ex. XXX-XXX-XXXX):

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* 19. Cell # (ex. XXX-XXX-XXXX):

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* 20. Full Name of Second Point of Contact in Case of Emergency

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* 21. Relationship to Camper:

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* 22. Primary Phone # (ex. XXX-XXX-XXXX):

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* 23. Work Phone # (ex. XXX-XXX-XXXX):

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* 24. Cell # (ex. XXX-XXX-XXXX):

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* 25. Full Name of Third Contact in Case of Emergency

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* 26. Relationship to Camper:

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* 27. Primary Phone # (ex. XXX-XXX-XXXX):

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* 28. Work Phone # (ex. XXX-XXX-XXXX):

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* 29. Cell # (ex. XXX-XXX-XXXX):

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* 30. Camper’s Health Card # (For Out-of-Canada campers: indicate any medical plan, numbers & billing address)

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* 31. Expiry Date:

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* 32. Family Doctor - Name

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* 33. Family Doctor - Phone # (ex. XXX-XXX-XXXX)

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* 34. Dietary Restrictions:

None

Vegetarian

Vegan

Lactose Intolerant

Gluten-Free

Other (please specify)

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* 35. Does your camper have any allergies? (Please note, we do NOT use or allow foods/snacks that contain nuts or traces of nuts.)

Yes