ECHO HILL RANCH
--60 Anniversary Summer--
2012 PERSONAL DATA FORM FOR: Campers & CIT I & II
To be completed by Parent/Guardian for each child registered
Please return form by May 1, 2012
This form may be submitted directly on line from our website,faxed to 3012-588-4041 or mailed to Winter Address: Echo Hill Ranch, 8601 Georgia Ave #810, Silver Spring, MD 20910
Indicate which session child is attending in 2012: Four-Week, Three-Week, One-Week,      Teen Leadership Camp I Or Teen Leadership Camp II (must be registered for Four Week Session to participate in leadership programs)
   Today´s Date: How did you find out about Echo Hill?
If you are new to Echo Hill, how did you find out about the camp?
   Rancher Name: Nickname:
   Date of Birth: Height:
   Weight: Gender:
   T-Shirt Size:
   School: Grade:
   Favorite Subjects: Parent(s) or Guardian(s):  
   Address:  
Street: City:
State: Zip:
   Parent’s Phone Numbers – Home, Work, and Cell:  
   Parents’ Email Address(es) that you are most likely to review regularly:
   If parents will be traveling during camp, please list    
alternative phone number or emergency contacts:  
   Family Doctor:  Phone:
   Doctor’s Mailing Address:
   Names/ages of siblings:
   Did either parent attend Echo Hill   If so when?
   Did this child attend Echo Hill? (Yes/No)
   Current School Attending and Grade Level 
   Has Camper attended camp other than Echo Hill? If yes,where and what was the experience like?
   PLEASE DESCRIBE CAMPER´S SKILLS,INTERESTS, HOBBIES AND STRENGTHS.

MEDICATION(S):Identify all prescribed and over the counter medication(s) and dosage(s) and the reason your child is taking this medicine
Medication(s)/Dosage(s)/Reason(s):

Medical and Emotional Concerns:
Please check if child si a subject to any of the following and describe your concern in the area below the table - this information will be confidential and is very important for us to be able to plan for a successful and safe summer for your camper.
Colds Food Allergies Bed Wetting Sore Throat
Asthma Abdominal Pains Fainting Spells Earaches
Skin Allergies Constipation Heart Disorder Headaches
Dehydration Sun sensitivity Sleep walking Separation Anxiety
Depression Anxiety ADHD/ADD Other (specify)
IF YOU´VE CHECKED ANY OF THE MEDICAL CONCERNS ABOVE, PLEASE DESCRIBE IN DETAIL YOUR CONCERN:

BEHAVIORAL CONCERNS:
Check the appropiate response and include detailed information for those areas you´ve rated as 'fair' or 'poor' include any strategies that are helpful at home, e.g. if your child is a 'picky' eater describe what that means and how you respond to it? 		Good Fair Poor
Eating Habits
Personal Hygiene
Sleeping Habits
Physical Coordination
Ability to get along with peers
Ability to get along with adults
   PLEASE ADD ANY ADDITIONAL FAMILY CONCERNS, SPECIAL ACTIVITY INTEREST OR BUNKHOUSE PLACEMENT REQUEST
  
   I HAVE SHARED ALL RELEVANT MEDICAL INFORMATION ABOUT MY CHILD THAT MAY AFFECT THEIR CAMP EXPERIENCE.
   Parent/Guardian:  Date: