Camper Emergency Form

Camper Information

Camper Name (First, MI, Last)required

Date of Birthrequired (mm/dd/yyyy)

Gender*

Male Female Non-binary

Grade*required

*For Summer Camp: list rising grade

Current FA student?*

Yes No

Current Schoolrequired

Home Address (Street, City, State, Zip)required

Parent/Guardian Information

Parent/Guardian Name (First, Last)required

Parent/Guardian Email Addressrequired

Is address same as camper?*

Yes No

Phone 1required

Phone 2

Parent/Guardian Home Address (Street, City, State, Zip)required

Parent/Guardian Employer and Addressrequired

Would you like to add a second Parent/Guardian?*

Yes No

Parent/Guardian Namerequired

Parent/Guardian Email Addressrequired

Is address same as camper?*

Yes No

Phonerequired

Phone 2

Parent/Guardian Home Address (Street, City, State, Zip)required

Parent/Guardian Employer and Addressrequired

Parents'/Guardians' Marital Statusrequired

Custody arrangementsrequired

Emergency Information

List TWO (required) emergency contacts, at separate addresses, in the event that the parents/guardians listed above cannot be reached. These contacts are authorized to transport the camper.

Emergency Contact Name (First, Last)required

Phonerequired

Relationshiprequired

Home Address (Street, City, State, Zip)required

Emergency Contact Name (First, Last)required

Phonerequired

Relationshiprequired

Home Address (Street, City, State, Zip)required

Transportation

Do you wish to add additional persons authorized to pick up camper?*

Current transportation includes Parent(s)/Guardian(s), Emergency Contacts

Yes No

Persons NOT Authorized for pick-up

Never, under any circumstances

Full Name (First, Last)required

Phonerequired

Relationshiprequired

Full Name

Phone

Relationship

Full Name

Phone

Relationship

Medical Information

Physician's Namerequired

Phonerequired

Insurance Companyrequired

ID #required

Special Medical Conditions*

Does your camper have any special medical conditions (health, physical restrictions, learning, medications, allergies, etc.) that we should know about to ensure a positive camp experience?

Yes No

Additional documentation may be required. Visit the 'Medical Forms' tab below.

List all allergies to food or medication:required

Does your camper need an EpiPen?*

If yes, an EpiPen must be provided to the Camp FA Nurse or Director on the first day of camp.

Yes No

List medications, times, and dosages:required

List learning or behavioral conditions below:required

List physical conditions below:required

Does your camper need an Inhaler?*

If yes, an Inhaler must be provided to the Camp FA Nurse or Director on the first day of camp.

Yes No