2020 SCOPES Camper Information Form

Please complete this form.

Camper Name Camper Name First Last
Parent 1 Name Parent 1 Name First Last
Parent 1 Email
Parent 1 Primary Phone Number Parent 1 Primary Phone Number - ### - ### ####
Parent 1 Alternative Phone Number Parent 1 Alternative Phone Number - ### - ### ####
Parent 2 Name Parent 2 Name First Last
Parent 2 Email
Parent 2 Primary Phone Number Parent 2 Primary Phone Number - ### - ### ####
Parent 2 Secondary Phone Number Parent 2 Secondary Phone Number - ### - ### ####
Additional Emergency Contact (Other than Parent 1 or 2) Additional Emergency Contact (Other than Parent 1 or 2) First Last
Additional Emergency Contact Relationship
Additional Emergency Contact Phone Number Additional Emergency Contact Phone Number - ### - ### ####
Family or Child's Physician
Physician's Phone Number Physician's Phone Number - ### - ### ####
Please List All Medical Information Here

Please note: if your child is taking medication during the school year, we strongly encourage continuing medication during this academic enrichment program. Please attach a letter authorizing our staff to dispense, and listing dosage amounts.
Please List Any Pertinent Educational or Behavioral Information Here

Please list all educational, behavioral, or other concerns of which we need to be aware, including any issues which might impact the camp experience of your child or other children.