Camp SMILE Application 2025

General Information
Child's Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Child's Age
Parent/Legal Guardian's Full Name
Realtionship to Child
Parent/Legal Guardian's Email Address
Parent/Guardian's Phone Number
Emergency Contact #1 (Name & Phone Number)
Emergency Contact #2 (Name & Phone Number)
If your child is not allowed to have contact with certain people/persons, please list their names and relationship to child below.
Your child will receive a free T-shirt. Please select the appropriate size for your child
Has your child attended Camp SMILE previously?
How did you hear about Camp Smile?

Health History
Does your child have any health concerns?
If yes, please explain
Is your child on any medications?
If yes, please list
Does your child have any physical injuries?
If yes, please describe injuries
Does your child have allergies to any of the following: foods, animals/insects, medicines, trees, plants, other
If yes, please list allergies
Insurance Information

Please provide your camper's insurance information below. This information is needed in case a medical emergency occurs.
Name of Insurance Carrier
ID#
Policy Holder
Claims # (on back of card)
Name of child's family doctor
Family doctor phone number
Should be Empty:

General Information