Health Form

This form is for your safety in the event of an emergency. Upon arrival at camp, you will seal this form in an envelope with your name on it, to be opened only in the event of an emergency. At the end of camp, you may ask for your envelope. Unretrieved envelopes will be taken to a professional shredder. Please include any additional information on the back.

Your Name: ___________________________________________________________________

Two different people to contact in an emergency:

Name: __________________________ Relationship: ____________ Phone: _______________

Your Birthdate (mm/dd/yr): _______________________

Primary Insurance Company: _____________________________________________________

Policy Number: ____________________________ Group Number: ______________________

Primary Holder: ____________________________

Secondary Insurance Company: ___________________________________________________

Policy Number: ____________________________ Group Number: ______________________

Existing Medical Problems: _______________________________________________________

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Allergies (include allergies to any medication): _______________________________________

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Medication Currently Taking (name, dose, times per day): ______________________________

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Primary Doctor: ____________________________ Phone: _____________________________

Please note that dancing, like any physical activity, carries the risk of injury and contagious illness. Neither Mainewoods Dance Camp, Inc., nor its members, officers, or directors has the resources to cover the costs of injuries or illness. While we don't want to discourage anyone from coming to Camp, your attendance is your representation that you have adequate insurance or other resources to cover your medical costs, lost wages, and pain and suffering without recourse to Mainewoods Dance Camp, Inc., or its officers, directors or members should you suffer any injury or illness.

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Signature Date