Camper Information

Child's First Name:required

Child's Last Name:required

Nickname

Name child would prefer to be known as (if different from first name)

Birth Daterequired (mm/dd/yyyy)

Returning Student:*

Yes No

Program:required

After Care*

Yes No

Current Schoolrequired

Graderequired

T-shirt sizerequired

Parent Information

Parent/Guardian #1:required

Addressrequired

Cityrequired

Staterequired

Zip Coderequired (ex. 06108 or 06108-0809)

Primary Phone Numberrequired

Emailrequired

Add another parent?*

Would you like to add information for an additional parent or guardian?

Yes No

Parent/Guardian #2:required

Address

City

State

Zip Code (ex. 06108 or 06108-0809)

Phone Numberrequired

Email

Medical Information

Emergency Contactrequired

In case of emergency, this person can be called.

Relationship to Camperrequired

Emergency contact's relationship to camper

Emergency Contact Phonerequired

Addressrequired

Cityrequired

Staterequired

Zip Coderequired (ex. 06108 or 06108-0809)

Child's Pediatrician:required

Phone & Ext. Block:

Phonerequired
Ext

Medical Insurance:required

Policy Number:required

Allergies:required

Allergy Description

Use this area to describe the allergies in more detail (hives, swelling, etc.)

Other Medical Conditions:

Any medical issue of which camp staff should be aware (seizures, serious illnesses, physical limitations, allergies to medications, non-life-threatening allergies, etc.).

Medication(s):

Dosage(s) & time(s) of day administered, if applicable:

Does your child wear glasses for reading?

Yes No

NOTE: A Doctor's Health Form will be required of all campers prior to commencement of the camp.

Parent Questionnaire

Strengths:required

How would you assess your child's major strengths?

Academic Needs:required

How would you assess your child's greatest academic need(s)?

Outside Interests:required

What outside interests does your child have?

Relationships:required

Describe your child's relationships with peers and/or other family members:

How did you learn about us?required

If other, please describe:

Photo Permission*

May we use photographs of your child participating in Odyssey Summer Camp activities?

Yes No