2019 Pennsylvania Family Camp Emergency Medical Form
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
Child's Middle Name
Child's Last Name
Date of Birth
Address Line 1
Address Line 2
Out of USA
Name of Pediatrician or Family Physician
Mother's (Guardian's) Name
Mother's (Guardian's) Daytime Phone
Mother's (Guardian's) Evening Phone
Father's (Guardian's) Name
Father's (Guardian's) Daytime Phone
Father's (Guardian's) Evening Phone
Name of Insurance Company
Insurance Group Number
Insurance ID Number
Insurance Company Phone
Has your child been affected in the past year by any of the following? Check all that apply.
Urinary Tract Infections
Abnormal Blood Pressure
Frequent Sore Throats
Frequent Nose Bleeding
Any other recent illnesses?
Has your child been immunized for the following? Check all that apply.
Date of last Tetanus booster:
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.
Can your child swim?
If applicable, has your daughter been informed about menstruation?
Please list any allergies:
Any other comments (e.g. fears, handicaps, etc.)?
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
Emergency Contact 1 Phone
Emergency Contact Name 2
Emergency Contact 2 Phone
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.
A copy of your responses will be emailed to the address you provided.
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