STUDENT INFORMATION
Student Name *
Student Name
PARENT CONTACT INFORMATION
Full Name of Parent / Guardian 1 *
Full Name of Parent / Guardian 1
Full Name of Parent / Guardian 2 *
Full Name of Parent / Guardian 2
Home Mailing Address *
Home Mailing Address
Primary Phone *
Primary Phone
Secondary Phone *
Secondary Phone
Work Phone *
Work Phone
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
MEDICAL
Name of Family Physician
Family Physician Phone Number *
Family Physician Phone Number
Medication *
My child takes medication on a routine basis.
If you answered "Yes" above, please list any medications being taken by your child on a regular basis including non-prescription drugs. Important: Make sure that your child arrives at MAMM each day with the exact amount of medication needed for that day. Keep all medications in their original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and frequency of administration. All medications must be given to the camp director when the child arrives each morning.
Allergies *
Does Student have any Allergies?
If you answered "Yes" above, please provide us with all of the necessary information regarding your child's allergies.
Name of Family Dentist
Family Dentist Phone Number *
Family Dentist Phone Number
MAMM is a unique learning situation where individual expression and teamwork go hand in hand. In order to help your child get the most out of their time at MAMM, we ask that you provide us with personal information regarding any LEARNING, BEHAVIORAL, or PERSONAL DIFFICULTIES they may have. Important: Any information you provide will be kept in confidence and will only be used to help provide a healthy learning environment for your child. If we are not aware of your child’s needs, we cannot help. With your help, we can make this program one of the most enjoyable educational experiences that your child will ever have.
MAMM Policies *
This health form is correct to the best of my knowledge, and the person named above has permission to participate in all activities except as noted. If I cannot be reached in an emergency, I hereby give permission to the physician selected by the director to hospitalize, secure proper treatment for, order injection for, or anesthesia for surgery for the person named above. In addition, I have read and understand MAMM’s policy above, regarding prescriptions, and agree to MAMM policies.