Camp Firefly Camper Registration
Saturday, Sept. 12 • Warriors’ Path State Park
Camper information
Please fill out the following information for the child attending. Please submit a new form for each additional child.
Camper Name
*
First Name
Last Name
Date of birth (mm/dd/yyyy)
*
(mm/dd/yyyy)
Gender
*
Male
Female
Non-binary
Current school grade
*
Current school name
*
Please note any physical, mental health or intellectual issues that should be brought to the attention of camp counselors, including diagnosis such as ADHD, autism, anxiety disorder or depression.
*
Please list any medications the child is currently taking.
*
Does the camper have any food or medication allergies? If so, please list those below.
*
Is the camper receiving professional support?
*
No
Yes, from school counselor
Yes, from social worker
Yes, from psychologist
Yes, from pastoral counselor
Yes, from family therapist
Unknown
Back
Next
Parent/guardian information
Please fill out the following information for the child's parent or guardian.
Parent/guardian name
*
First Name
Last Name
Relation to camper
*
Address (yours if different from camper)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Back
Next
Emergency contact information
Same as parent/guardian listed above
*
yes
no
If "no," please enter the following information:
Name
First Name
Last Name
Relation to camper
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Back
Next
Other authorized person to pick the child up from camp, if any.
If none, enter "none"
Name
*
First Name
Last Name
Back
Next
Bereavement information
Name of the deceased
*
Camper relationship to the deceased
*
Age of the deceased
*
Date of death
*
Age of the child when the death occurred
*
Where did the death occur
*
Did the camper attend the funeral or memorial service?
*
yes
no
unknown
What was the child’s reaction to the death?
*
How was the loss explained to the child?
*
Have there been other recent deaths experienced by the child? (If yes, who and when?)
*
Have there been any other changes in the child’s life (examples: divorce, remarriage, relocation, illness, etc.)?
*
Signature
Submit
Should be Empty: