Heart Camp Event Registration

Camper Information

Additional Information About Camper

In case the first choice is not available.

Ex. school activities, spending time with friends and enjoying other activities, etc.
Ex. what do camper enjoys.
Ex. shy, outgoing, friendly, etc.

Ex. sleepwalking, nightmares, awakening, bedwetting, snoring.

Ex. crutches, wheelchair, prosthesis, feeding pump, nebulizer, etc.
If yes, please be sure to provide these items with your child at camp.

These include outside the home or been physically aggressive with others?

If you answered yes, you will be contacted by Kids Heart Camp leadership for more information about the specific situation. It is important to answer truthfully.

Medical Status Information

Ex asthma, ADD, diabetes, etc.

Only females campers are required to answer this question

**All immunizations must be up to date and a copy of immunization record included with application**

Parent/Guardian Information

Second Parent/Guardian Information

Emergency Contact Information

The emergency contact should be someone other than parent/guardian. Parents/guardians will be contacted first, followed by the emergency contact.

Cardiologist Information

e.g. UT Health San Antonio, University Medicine Associates, etc.

Pediatrician Information