Emergency Forms for Camps
Please print out the receipt AFTER you submit and keep for confirmation. You must fill out Agreement Form for each camp you are registering for as well.

All staff will be certified by the American Heart Association in Standard First Aid/CPR. Additionally, all lifeguards are certified. Thus, the staff will provide a safe environment for your child at camp, but accidents do happen. For this reason we are requesting that this form be completed for each child that is registered for the Summer Program. The information included on this form is very important to our staff should an emergency arise. It will also be made available to emergency personnel and/or accompany your child to the physician or hospital should your child need immediate emergency care. In all cases we will make every effort to reach you if an emergency should arise. Treatment will not be given without your permission unless it is an emergency. All information will be kept confidential.

Child's Name *
Please list First and Last Name
Your answer
Age *
This form is being used for multiple camps. Preschool Summer Adventures is for ages 3 - 5, Siebert Park Day Camp is ONLY for 5 - 12 year olds. Grades Entering 1st - 6th. Also Theatre camps have a range of ages depending on the camp. Please look at description for each camp.
Birth Date *
m/d/y
Your answer
Grade Completed *
As of June 2018. This form is being used for multiple camps. Siebert Park Day camp is ONLY for Entering 1st - Entering 6th
Home Address *
Your answer
First Parent's Name (Or Legal Guardian) *
Please First and Last Name
Your answer
First Parent's Address if different than child's
Your answer
First Parent's Occupation and Employer's Phone Number & Address *
Your answer
Your answer
First Parent's Email Address
Your answer
First Parent's Home Phone Number
Your answer
First Parent's Cell Number
Your answer
Second Parent's Name (Or Legal Guardian) *
Please First and Last Name
Your answer
Second Parent's Address if different than child's
Your answer
Second Parent's Occupation and Employer's Phone Number & Address *
Your answer
Second Parent Email Address
Your answer
Second Parent's Home Phone Number
Your answer
Second Parent Cell Number
Your answer
Emergency Contact Name *
To be contacted if a parent can't be reached.
Your answer
Emergency Contact Relationship *
Your answer
Emergency Contact Phone Number *
Your answer
Special Dietary or Medical Information
Your answer
Please List Allergies
Your answer
Please List Any Chronic Problems
Your answer
Does your child require any accomodations to participate in camp?
Your answer
Does your child require any accomodations to participate in camp?
Your answer
Immunization *
Required
Date of Last Tetanus Shot *
Your answer
Hospitalization History *
When and Why?
Your answer
Medications Child is Currently Taking
Your answer
Family Doctor
Your answer
Family Doctor Phone Number
Your answer
Medical Insurance Carrier
Your answer
Medical Insurance Carrier
Your answer
Please list perference for the following should service or advice be required
Ophthalmologist
Your answer
Ophthalmologist Phone Number
Your answer
Orthopedic Surgeon
Your answer
Orthopedic Surgeon Phone Number
Your answer
Hospital
Your answer
Hospital Phone Number
Your answer
Hospital Phone Number
Your answer
Parent/ Guardian Acknowledgement
I (We) verify that the information provided on this form is complete and accurate. I (We) also give my (our) consent for my (our) child to receive emergency medical care and/or be transported by our staff or Camp Hill EMS personnel in an emergency.
Parent/Guardian Permission *
Required
If Your Child Requires Medication During Camp, Please Complete the Information Below. *
Required
Name of Medication
Please list name of medication, reason for taking it, dosage and time for medication, side effects (if any), Duration of Medication, Must take with
Your answer
Parent / Guardian Ackowledgement
I give staff of Siebert Park Day Camp, Preschool Summer Adventures, or Theatre Camps permission to administer the above listed medication to my child as directed. I understand the medication is to be in its labeled container with physician’s approval. Parents should put in writing any additional instructions with the Camp Director.
Parent/Guardian Permission *
Required
Camp Registering For
Please check which camp your child will be attending. Please NOTE if your child is attending Siebert Park Day Camp and Theatre Camp, check box that has both in it.
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