Basic Information
Full Name
Emma Chen-Rodriguez
Date of Birth
March 14, 2016
Gender
Girl
School
Maple Ridge Elementary
Grade
4th Grade
T-Shirt Size
Youth M (8–10)
Emergency Contacts
Lisa Chen
Parent 1 · Mother
(415) 555-0182
lisa.chen@email.com
Marco Rodriguez
Parent 2 · Father
(415) 555-0247
marco.r@email.com
Medical Information
Allergies
Peanuts (Severe)
Bee stings (Moderate)
Medications
EpiPen (Epinephrine auto-injector)
Carried in backpack at all times · Prescribed by Dr. Sarah Kim
Dietary Restrictions
None listed
Special Accommodations
None listed
Insurance Information
Provider
Blue Shield CA
Policy Number
BSC-8847-2091
Group Number
GRP-44190
Authorized Pickup
Lisa Chen
Mother (Primary guardian)
(415) 555-0182
Marco Rodriguez
Father (Primary guardian)
(415) 555-0247
Grace Chen
Grandmother
(415) 555-0309
Preferences & Notes for Camps
"Emma is shy at first but warms up quickly once she feels comfortable. She absolutely loves animals — especially dogs and horses — and has a real talent for art and crafts. She can get overwhelmed in very loud or chaotic environments, so a heads-up about particularly loud activities helps her prepare. She's a wonderful kid who will surprise you!"
Documents
4 on file
Physical Exam
Uploaded Jan 15, 2026
Immunization Record
Uploaded Jan 15, 2026
Insurance Card (front & back)
Uploaded Feb 3, 2026
Photo ID
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