Camper Special Dietary Needs Form
Camp Start Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Camp End Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Camper Information
Camper Name
*
First Name
Last Name
Camper Age
Gender
Male
Female
Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Back
Next
Parent Information
Parent or Guardian Name
*
First Name
Last Name
Relationship to Participant
*
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Back
Next
Food Allergies
*
Yes
No
What are they?
Milk
Wheat/Celiac/Gluten-Free
Eggs
Soy
Vegetarian
Other
What is the severity of your allergies listed above?
Severe
Moderate
Mild
Sensitive
Other information we may need to know about these allergies?
Other special diet needs or restrictions
Signature (Parent)
*
Submit
Should be Empty: