Your Email*:

Campers Name*:

Age*:

Date of birth*:

Grade entering*:

Address*:

Town*:

State*:

Zip*:

Parent/Guardian name*:

Home phone*:

Work phone:

Cell phone:

If Parent/Guardian is unavailable, please list an adult familiar with your child that we may call in case of emergency.

Name*

Relation (neighbor/friend)*:

Home phone*:

Work phone:

Cell phone:

Medical Information

Insurance Company*:

Policy #*:

Camper physician*:

Telephone*:

Camper dentist*:

Telephone*:

Does your child have any allergies*?
 Yes No

If yes, please explain:

Does your child have any medical conditions that we should be aware of*?
 Yes No

If yes, please explain:

Will your child be taking any medication at home – prior to the camp day*?
 Yes No

If yes, please explain:

Is your child on any medications that they will bring to camp*?
 Yes No

If yes, please explain:

IMMUNIZATION RECORDS

The Andover Board of Health is very strict with regard to the physical status of each and every camper planning to attend Lazer Lax. We are required to have a current immunization record and a copy of each child’s most recent physical exam (dated within 24 months of attending camp) on site – for every camper. In order for us to accept your child’s application to Lazer Lax you must send a current immunization record from your physician and a copy of your child’s most recent physical exam (which must be dated within 24 months of attending camp)

RELEASE STATEMENT

I, the parent/guardian of the above named camper, give permission for my child to receive emergency medical treatment and hospitalization, if necessary. I understand that every attempt will be made to contact me, or the named alternate contact above, before taking this action. By enrolling my child, I ensure that he is physically and mentally able to participate in all of the programs activities. I hereby waive and release Lazer Lax Lacrosse – its directors and staff from any liability for any injury or illness incurred while attending camp. I understand that there is a risk of injury to my child as a result of camp activities, and knowingly and voluntarily assume all risk of such injury. I will be financially responsible for any medical attention needed during camp or resulting from an injury received at camp. My medical insurance shall be the insurance coverage for any medical treatment.

 I give permission I do not give permission

Additional Information