CAMP GINKGO Insurance/Medical Info Form
WEST PARK CULTURAL CENTER
Mailing Address: 5114 Parkside Avenue * Philadelphia, PA 19131
215/473-7810 www.westparkcultural.org 
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Child's Name *
Date of Birth *
Age *
Sex
School Child Attends *
Name of Parent/Guardian *
Address *
City *
State *
Zip *
Home Phone
Day Time Phone
Cell Phone *
Email *
Emergency Contact *
Relationship *
Emergency Contact Phone *
Name(s) of persons authorized to pick up your child
Medical Information
Insurance Provider
Insurance Group#
Name of Child's Physician *
Phone *
List of medical conditions child may have
List of any prescription medication your child is taking
I, (parent/guardian name)
I give permission for my (child) to participate in West Park Cultural Center’s Camp Ginkgo to be held at the Fairmount Park Horticulture Center. I understand the camp period each week is Monday thru Friday from 8:00am to 3:00pm.  I further understand that if my child is picked up after 3:00pm on regular days, I will be charged a $10 extended day fee. *
Signature of Parent/Guardian *
Date *
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