Summer Camp 2021-2022
Jim Thorpe Summer Day Camp
Please provide the date in which the registration was completed.
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Parent/Guardian Name(s): *
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Please Type Campers Full Name: *
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Age of Camper: *
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Current Address: *
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Contact Information (cell phone number): *
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Contact Information (work number): *
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Contact Information (email address)
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Allergies (food/ drug): *
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Medical Problems ( Diabetes, Asthma, etc) *
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Is there any required medication your child must take?  (If yes please list) *
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Emergency Contacts Name: *
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Emergency Contacts Phone: *
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Who will be dropping off/picking up the camper? (Name and relationship to the camper) Please list ALL individuals that will be picking camper up as we will be asking for ID to ensure they are listed: *
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Is the campers' photo permitted to be taken to be used on our Facebook Page? *
May the camper leave Memorial Park (with counselor supervision) for nature walks and other activities?
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