2020 Summer Camp Registration Form
Summer Camp at Chesterbrook Academy, West Chester, PA
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Email *
Alternate email
Camper's Name *
Male or Female *
Address *
Camper's Birth Date *
MM
/
DD
/
YYYY
Age on June 1st *
Camp t-shirt size *
Grade in the Fall *
Parent/Guardian 1 *
Parent/Guardian 1 *
Home Phone *
Cell Phone *
Business Phone *
Parent/Guardian 2
Parent/Guardian 2
Clear selection
Home Phone
Cell Phone
Business Phone
Child is in custody of (Please check one) *
Child lives with (Please check one) *
Does your child know how to swim? *
Do you give permission for your child to swim in camp programs? *
Do you give permission for your child to attend and participate in all activities on camp field trips? *
Family Physician *
Family Physician Address *
Family Physician Phone *
Dentist/Orthodontist *
Dentist/Orthodontist Address *
Dentist/Orthodontist Phone *
Medical/Hospital Insurance Carrier (Note:  Please submit copy of insurance card) *
Health History (Mark all that apply & provide copies of all immunizations) *
Required
Allergies (Mark all that apply) *
Required
If allergic to insect stings, food, or other, please list type
Operations, serious injuries, diseases, or restrictions on physical activity *
Current medication and purpose (all medication sent to camp must be given to camp director and labelled clearly with doctor's instructions) *
Behavioral conditions of which camp staff should be aware *
In addition to parent/guardian names listed above, these person(s) have permission to pick up my child from camp.  I understand that my child will not be allowed to leave with any person without authorization from parent/guardian, and that the person picking up my child will need to show identification. (Include name, phone number, relation and drivers license number) *
Parent Authorization/Medical Release:  The information provided is correct to the best of my knowledge, and the person described has my permission to engage in all prescribed camp activities, except if noted by me.  In the case of sickness or accident, I hereby give permission to the medical personnel selected by the camp representatives to order x-rays, routine tests, treatment, dental work, and necessary transportation for the recipient at my expense.  In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp representative to secure and administer treatment, including hospitalization, for my child as named above.  This form may be photocopied for use away from the main program site.  I authorize NLCI staff to apply sunscreen to my child's exposed skin on an as needed basis - if child needs assistance.  All photos that are taken of my child may be used for promotional purposes. *
If no, please explain:
A copy of your responses will be emailed to the address you provided.
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