Medical Form — Camp Maxx NJ

Camper Information

The boy attending camp.

Camper Full Name Date of Birth Age at start of camp Grade entering (Fall 2026) School Home Address City

State ZIP Shirt Size

Bunk / Division (if known)

Parent / Guardian

Parent / Guardian Name Relationship Mobile Phone Email Second Parent / Guardian Name (optional) Second Parent Mobile (optional)

Emergency Contact

Someone other than the parent above, in case we can't reach you.

Name Relationship Phone

Primary Physician

Physician Name Physician Phone Date of Last Physical

Health Insurance

Insurance Company Policy / Member ID Group # Primary Insured (subscriber) Name

Medical History

Type "None" where applicable — please don't leave blank.

Allergies (food, medication, environmental) Current medications & dosages Chronic conditions (asthma, diabetes, epilepsy, ADHD, anxiety, etc.) Recent illnesses, surgeries, or injuries (past 12 months) Will the camper carry an EpiPen or rescue inhaler at camp? Cleared for full physical activity (swim & contact sports)? Restrictions or accommodations (if any) Tetanus / Tdap booster (date) Notes for camp medical staff (anything else we should know)

Authorizations & Signature

Required to complete registration.

Photo / video release. I grant Camp Maxx permission to photograph and video my child during camp activities for use on the Camp Maxx website, social channels, and promotional materials. (Leave unchecked if you decline.) Consent & truth affirmation. I am the parent or legal guardian of the camper named above, I am at least 18 years old, and I authorize Camp Maxx staff and medical personnel to provide first aid, administer the medications listed, and — in an emergency — seek emergency medical care including hospital transport if I cannot be reached immediately. The information above is true and complete to the best of my knowledge.

Electronic Signature (type your full legal name)

By typing your name above and submitting this form, you agree that your typed name constitutes your legal electronic signature under the federal E-SIGN Act and the New Jersey Uniform Electronic Transactions Act. Your IP address and submission timestamp will be recorded with this form.

Camper Medical Form