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LCA Summer Camp Health Form

Student Information

Gender*
Answer Required
State*
Answer Required

Parent/Guardian 1 Information

Parent/Guardian 2 Information

Emergency Information

Student Health Information

Condition*
Answer Required
Yes
No
Allergies (food, insects, drugs, latex)
Allergies (seasonal)
Allergies to Medication
Arthritis
Asthma or Breathing Problems
Attention-Deficit/Hyperactivity Disorder
Autism Spectrum Disorder
Behavioral Concerns
Chronic Bronchitis
Dental Concerns
Developmental Concerns
Diabetes
Emotional Concerns
Frequent Constipation
Frequent Diarrhea
Frequent Ear Infections
Frequent Headaches
Frequent Stomach Aches
Frequent Nosebleeds
Hearing Concerns or Deafness
Heart Concerns
Hypoglycemia
Orthopedic Concerns
Seizures
Speech Problems
Vision Concerns
Do you give permission for your student to use hand sanitizer? *
Answer Required
Do you give permission for your student to use sunscreen? *
Answer Required
Confirmation Email