LUMIN: Summer Healthcare Camp

Summer Camp: Bridging the next generation with healthcare professions
Please mark the dates that your child will be attending the camp:

Please mark the dates that your child will be attending the camp: June 12th, 2023 June 13th, 2023
Child's Information
Child's Name Child's Name First Middle Last
Child's Gender

Child's Gender Male Female
Child's T-Shirt Size
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Year of Graduation
Grade Entering in the Fall
Parent or Legal Guardian Information
Parent/Legal Guardian Name Parent/Legal Guardian Name First Last
Parent/Legal Guardian Relation
Work Phone
Work Phone Work Phone - ### - ### ####
Cell Phone
Cell Phone Cell Phone - ### - ### ####
Parent/Legal Guardian #2 Name Parent/Legal Guardian #2 Name First Last
Parent/Legal Guardian #2 Relation
Parent/Legal Guardian #2 Work Phone
Parent/Legal Guardian #2 Work Phone Parent/Legal Guardian #2 Work Phone - ### - ### ####
Parent/Legal Guardian #2 Cell Phone
Parent/Legal Guardian #2 Cell Phone Parent/Legal Guardian #2 Cell Phone - ### - ### ####
Emergency Contact Information
Emergency Contact Name (if parent or guardian is not available)
Home Phone Home Phone - ### - ### ####
Home Phone
Emergency Number Emergency Number - ### - ### ####
Emergency Number
Emergency Number #2 Emergency Number #2 - ### - ### ####
Emergency Number #2
Email Confirmation
Parents Email
Child's Email
Health Information

If nothing applies, please put "NONE" in the box.
Any activity the child should be restricted from?
Any physical, mental or other condition that would require special attention or medication while at camp?
List any past medical treatment that would be helpful for us to know.
List any allergies

ex: bees, peanuts, dairy, ect.
Any dietary needs that we should know about?
List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.
Agreements

Agreements I am the parent or legal guardian of the above named camper, and am over the age of 18. In case of medical emergency or general medical care, I give consent for medical treatment for the above named camper by authorized personnel. I understand that the above named camper will only be released to the names listed above (an update may be done at registration). I certify that my child has my permission to attend camp and participate in all activities. I authorize that the camp host may use my child's picture, testimony, and video in any promotional material (web, print, or media).

LUMIN: Summer Healthcare Camp

Summer Camp: Bridging the next generation with healthcare professions

Child's Information

Parent or Legal Guardian Information

Emergency Contact Information

Email Confirmation

Health Information