2014 University Health Care Burn Trauma Center’s River Rafting Expedition Camper Application

Note: All information on this application form is necessary if we are to provide a safe, secure environment for your children during camp. Campers will not be accepted to Burn Camp unless every item of the application is filled out completely. This form is located on a secure server.
* Required





















Emergency Contacts

Please provide us with the names and telephone numbers of two other people we can contact in case of an emergency.












Note:

If your child is currently or has previously received counseling or psychotherapy, a brief summary statement from his or her therapist indicating treatment issues as well as issues relevant to camp is required as part of the application process. This need not be lengthy. Its intended use is to guide and assist us in providing for your child a camp experience that will build on counseling goals. Your therapist’s report can be included with the camp application material or sent directly to: Brad Wiggins R.N. BSN Burn Camp Director 50 North Medical Drive Salt Lake City, Utah 84132

Burn Injury













Completion

By filling out the section below I am stating that the information I have given about the so named camper is complete to the best of my knowledge and that I am consenting to electronic submission of these forms.


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