Camp Application Form

Campers Name:

Gender:

Date of Birth:

Address:

Contact no.s:

Email:

Class:

School:

How did you come to know about Break Loose?

Information of parent(s) or guardian at same address as camper

Full Name:

Relationship:

Full Name:

Contact no.s:

e-Mail:

Medical Details

Medical problem (if any):

Drug allergies (if any):

Has the child been under any kind of medication recently?

Any specific activity to be encouraged or limited by physician's advice?

Has the child undergone any surgery?

Medication, in case any, desired at the camp: