Medical Waiver & Emergency Form

"*" indicates required fields

A medical waiver & emergency contact form is required for each camper. Please provide copies of immunization records and a complete physical for each child NOT currently enrolled at Wakefield Country Day School.

Participant's Name*

First Last

Date of Birth*

Parent/Guardian Name*

First Last

Email*

Cell Phone*

Work Phone

Address*

Street Address Address Line 2 City State ZIP Code

Emergency

In case of emergency, when parent/guardian can't be reached, please call:

Name*

First Last

Relationship*

Cell Phone*

Other Phone

Medical Information

Participant's Physician*

Phone*

Health Insurance Provider

Policy Number

Allergies (Please Specify)

Current Medication

Significant Past Injuries or Illnesses (Please Specify)

Date*