Camper Information - Montgomery Whitewater

Camper's Full Name(Required)

First Middle Last

Camper's Preferred Name

Camper's Birth Date(Required)

Camper's Age(Required)

Camper's Gender(Required)

Which camp are you attending?

MultiSport Camp

Kayak Camp

Week of Attendance(Required)

Parent/Guardian Name(Required)

First Last

Relationship to the Camper(Required)

Parent/Guardian Phone Number(Required)

Alternate Parent/Guardian Phone Number(Required)

Parent/Guardian Email Address(Required)

Parent/Guardian Home Address(Required)

Street Address City State ZIP Code

Emergency Contact Name(Required)

In case a parent/guardian cannot be reached.

First Last

Emergency Contact Relationship to Camper(Required)

Emergency Contact's Phone Number

Does the camper have any allergies?(Required)

(food, insect stings, medication, etc.)

yes

no

If yes, please list:

Does the camper have any medical conditions we should be aware of?(Required)

yes

no

If yes, please describe:

Does the camper carry an EpiPen or inhaler?(Required)

yes

no

Primary Physician's Name(Required)

First Last

Primary Physician's Phone Number

Health Insurance Provider(Required)

Policy Number

Please list authorized Pick-up Persons(Required)

If not a parent or guardian listed previously, a valid ID must be presented.

Phone

This field is for validation purposes and should be left unchanged.