2019 Pennsylvania Family Camp Emergency Medical Form
Email address *
To Parents/Guardians:
Please fill in this form completely (one form per child) as soon as possible. AS PER THE RULES ISSUED BY THE DEPARTMENT OF CONSERVATION & NATURAL RESOURCES OF THE STATE OF PENNSYLVANIA, ALL CAMPERS MUST HAVE THIS FORM AT THE CAMP. If we do not receive this form by July 6, we reserve the right to refund the money already submitted and fill the available space from our waiting list.
Child's First Name *
Your answer
Child's Middle Name
Your answer
Child's Last Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Gender *
Address Line 1
Your answer
Address Line 2
Your answer
City
Your answer
State
Zip Code
Your answer
Country
Your answer
Name of Pediatrician or Family Physician
Your answer
Physician's Phone
Your answer
Mother's (Guardian's) Name
Your answer
Mother's (Guardian's) Daytime Phone
Your answer
Mother's (Guardian's) Evening Phone
Your answer
Father's (Guardian's) Name
Your answer
Father's (Guardian's) Daytime Phone
Your answer
Father's (Guardian's) Evening Phone
Your answer
Name of Insurance Company
Your answer
Insurance Group Number
Your answer
Insurance ID Number
Your answer
Insurance Company Phone
Your answer
Has your child been affected in the past year by any of the following? Check all that apply.
Any other recent illnesses?
Your answer
Has your child been immunized for the following? Check all that apply.
Date of last Tetanus booster:
MM
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DD
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YYYY
If your child needs to take any medication while at camp, please tell us the name of the medication and the dosage information, which should be brought with the medication.
Your answer
Can your child swim?
If applicable, has your daughter been informed about menstruation?
Please list any allergies:
Your answer
Any other comments (e.g. fears, handicaps, etc.)?
Your answer
If you want, you can list two people here who can act on the child's behalf if you cannot be reached.
Preferably, this should be someone who will be there.
Emergency Contact Name 1
Your answer
Emergency Contact 1 Phone
Your answer
Emergency Contact Name 2
Your answer
Emergency Contact 2 Phone
Your answer
Waiver Signature (your name)
I, the parent/guardian of the minor named in this form, agree that Shehaqua Family Camp and Pocono Family Ministries and their staffs can act on my behalf to authorize or refuse medical treatment for my child, until I can be reached, while my child is participating in activities and programs hosted or sanctioned by Shehaqua Family Camp or Pocono Family Ministries. I understand that I am responsible for the payment of all costs incurred by such treatment. I will not hold Shehaqua Family Camp or Pocono Family Ministries responsible or liable for accidents or injuries that are not wholly due to the facilities, acts, or omissons of Shehaqua Family Camp and Pocono Family Ministries.
Your answer
Signature Date
MM
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DD
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YYYY
A copy of your responses will be emailed to the address you provided.
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