2010 New Life Ranch Health Form

You are about to fill in the 2010 health form. This is not the registration form for Camp. If you have not registered for Camp please register first. Filling in this health form will not reserve a spot at camp.

Once you start filling in the form you will not be able to save it and come back later. It must be completed or you will have to refill the info. To complete the health form you will need the following information:

Name of Family Physician
Physician's Phone Number
Date of Last Physical Exam
Name of Orthodontist/Dentist
Orthodontist/Dentist's Phone Number
Prefered Pharmacy for Prescriptions
Date of last tetanus booster
The following insurance information:
- Health Insurance Carrier
- Mailing Address
- Policy Number
- Group Number
- Co-pay Amount
- Deductible Amount
- Primary Policy Holder Name (GUARANTOR)
- Employer
- Policy Holder ID (may be your Social Secrurity Number)
- Policy Holder Date of Birth
- Camper Insurance ID (may be your camper's Social Secrurity Number)
- Camper Date of Birth
Relevant medical information (medical history, allergies, etc)

If you know the registration number from your camper's Camp on-line registration, we can retrieve much of the Health Form information from that registration form. Just supply your camper's name and the registration number, exactly as they were entered on the Summer Camp form, here (You cannot change the information from the Summer Camp registration. If it needs to be corrected, please contact the camp.)

Camper First Name:
Camper Last Name:
Registration Number:

If you do not have the registration number, you can still fill out the health form on-line. You will just have to supply all of the required information.