First Name *

Last Name *

Preferred Name *

Gender * Male Female

Birthday

Preferred Language * English Spanish Sign-Language Other

Other Language not listed above:

Marital Status * Married Single

T Shirt Size * S M L XL XXL XXXL

How are you participating with us? Select one option. * Volunteer/Staff Friend (adult with a disability) Parent/ Guardian Caregiver Family member Spouse Other (please indicate below)

Other Role not listed above:

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Relationship *

Do you have a disability? * Yes No

List your disability condition(s):

Do you have any FOOD allergies? * No Yes

List FOOD Allergies

Do you have any Dietary Restrictions? * No Yes

Dietary Restrictions

Do you have any MEDICATION or ENVIRONMENTAL allergies? No Yes

LIST ALL MEDICATION and ENVIRONMENTAL ALLERGIES

What MEDICATIONS do you take to treat your allergies and/or what ACTIONS do you take to prevent/avoid a reaction?

What happens if the allergy/reaction is not treated appropriately?

Please list ALL Medications you take (Name, dosage, & time taken) *

Please indicate if you have any of the following emergency medical conditions: *

Please list medications/interventions needed to treat your emergency condition(s):

Do you use any mobility or medical devices or equipment ? * No Yes

Select all mobility devices used

Other Mobility or Medical Device not listed

I give Camp David Medical Personnel permission to administer the following Over-the-Counter medications, in the usual prescribed dose, if they feel it is medically appropriate/ necessary:

Insurance Carrier *

Policy Number *

If you have secondary insurance coverage, enter carrier and policy number here:

Where do you attend church?

By checking this box, I confirm that I have reviewed this form and made updates if needed. *