Name:_____________________________

Home Phone:_____________

Address:___________________________

Work Phone (M)___________

City:______________________________

Work Phone (F)___________

State:_________________Zip:_________

Family Physician:____________________

Phone:__________________

Describe Any Health Problems We Should Be Aware Of:

________________________________________________________________

________________________________________________________________

________________________________________________________________

In The Event Of Illness Or Injury If Parent Not Available Who May We Contact:

Name:___________________Relationship_______________Phone:__________

Name:___________________Relationship_______________Phone:__________

In The Event Your Child Needs Emergency Care May We Take Child To The Nearest Hospital For Treatment?  □ Yes    □ No

Insurance Company:________________________Policy#____________________

By signing this form I understand that I will NOT hold CFO liable for injuries or illness, or the medical treatment that my child receives.

Parent Signature:_____________________________________________________

This form must be filled out completely, including parent signature, for child to be allowed to attend camp and received no later than 14 days before camp.