LP Students Middle School Winter Retreat

First Name *

Middle Name

Last Name *

Date of Birth *

Gender

Parent/Guardian Name *

Parent/Guardian Phone Number *

Health History *

Allergies: *

Chronic or recurring illness or medical condition (otherwise not listed above): *

Any treatment to be continued at camp:

Any medically prescribed meal plan or dietary restrictions: *

Activities to be discouraged or limited:

Additional health information for camp personnel: *

Describe any physical condition, medications or allergies that require special consideration: *

Current medications (send with instructions in original container): *

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