CRM 115

Camp Program

Applicant First Name

Applicant Last Name

Applicant Age

Birthdate

Weight

Height

Address Line 1

Address Line 2

City

State

Zipcode/Postal Code

Parent First Name

Parent Last Name

Phone

Relationship to Applicant

Applicant Lives With

Emergency Contact First Name

Emergency Contact Last Name

Emergency Contact Phone. Preferably mobile.

Emergency Contact Relationship to Applicant

Pertinent Non-Medical Information

Do any members of the applicant’s family have a history of heart disease, diabetes, seizures, mental or emotional illnesses?

Does the applicant have any present physical illness or disability?

Does the applicant have a history of or currently have any emotional or mental illnesses including but not limited to: depression, anxiety, autism, Down Syndrome?

Does the applicant have a history of behavioral problems, drug or alcohol use?

Will the applicant be taking any medications during the time of the program?

Does the applicant have a history of sleep disorders (e.g. sleepwalking, wetting the bed, insomnia, nightmares, etc.)?

Has the applicant ever been hospitalized or had surgery?

Allergies?

Asthma?

Common childhood diseases?

Seizures?

Frequent colds or sore throats?

Depression?

Frequent earaches?

Frequent or severe headaches?

Heart murmur or heart abnormality?

High blood pressure?

Has the applicant ever had severe reactions to an insect bite?

“Passed out” or “knocked out”?

Shortness of breath?

Concussion?

Skin problems?

Please explain all 'Yes' answers to the above list. If the applicant requires any particular consideration, care, medication, (e.g. epipen, protective head gear for sports, etc.) please explain here.

Please note any other pertinent medical history details:

Hearing Aid?

Glasses?

A special diet? (e.g. Allergies)

Any other special requirements we should be aware of?

If any special requirements, please list them here.

Covered by insurance?

Insurance Coverage First name

Insurance Coverage Last name

Insurance Company Name

Insurance Address 1

Insurance Address 2

Insurance Address City

Insurance State (2 Letter Abbrev.)

Insurance Zip

Insurance Policy Number

By completing this application, I acknowledge and agree to all of the terms, release, and consent detailed on the organization website, and required by Bosco Ministries (St. John Bosco Camps), as the applicant's parent or legal guardian.

Bosco Ministries Boys Programs General Application