P.O. Box 1156 THIS FORM MUST BE MAILED BACK!

Winona, MN 55987
PH/FAX: 800-345-7235 We require that this original be on file
E-Mail: info@peakhockey.com for each camper prior to arrival at camp!

PLEASE DO NOT E-MAIL

THIS FORM BACK TO US!

Health Information

The information requested will be used to provide proper medical treatment to

the camper in the event that the need arises. Please fill out completely, print
clearly, and return with the remaining balance of your account or send in prior to
your child attending camp. Return Form Prior To May 15, 2010!

NAME:_________________________________________ GENDER:_______
Last First MI

DATE OF BIRTH:______-_____-_____ AGE:________(at time of camp)

Parents Names: ___________________________________________________

IN CASE OF EMERGENCY, NOTIFY:__________________________________

ADDRESS:_______________________________________________________
Street City State Zip

PHONE NUMBER(S):______________________________________________

RELATIONSHIP TO CAMPER:_______________________________________

ALTERNATE CONTACT IN CASE OF EMERGENCY:_____________________

________________________________________________________________

ADDRESS & PHONE NUMBER(S):____________________________________

FAMILY PHYSICIAN:________________________ PHONE:_______________

ADDRESS:_______________________________________________________
Street City State Zip

INSURANCE CARRIER _______________________________________

POLICY NUMBER____________________________________________

Age Group:_________________________________ Dates Attending:________________

PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM