Summer Camps Request Form

Reservation Information

Camper Information

Address:

Mother/Guardian Information

Father/Guardian Information

Emergency Contact Information

Person other than parent/guardian preferred.

Health Conditions

Allergies:
Does your camper take any medications on a regular basis:
If yes, does this need to be administered at camp:

Authorized to Pick Up

Additional Information for Camp Staff or Coordinator

I heard about MPM Camps

By submitting this form, you acknowledge that you are the parent/legal guardian of the dependent specified in the Camper Information section. As the parent/legal guardian, submission of this form gives your consent for emergency medical or dental care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of the dependent.