PEEC Day Camp Registration

To register online, complete the form below including registration information, emergency contact information, emergency medical information and medical history. When completed, click the Submit button at the bottom of the page to be transfered to the Camp Session selection and payment page. In the event you need to cancel, please notify PEEC in writing at least two weeks prior to the program. Your camp fees, minus $25/child, will be refunded.

REGISTRATION INFORMATION

Child's Full Name
A value is required.

Nickname

Child's Birthday (MM/DD/YYYY)
A value is required.A value is required.Invalid format.

Grade (as of September 2011) Please select an item.
Gender Please select an item.

Parent/Guardian Full Names
A value is required.

Address A value is required.
City A value is required.	State A value is required.	Zip A value is required.
Home Phone A value is required.	Work Phone	Cell Phone

Email Address
A value is required.

Individual Authorized for Child Pick-Up
Name	Relationship to Child

Camp information will be sent via email. If you prefer to receive information by regular mail, please check the following box.
Receive information by mail

EMERGENCY CONTACT INFORMATION

In Case of Emergency Notify:

Name	A value is required.
Relationship	A value is required.
Phone	A value is required.
Name
Relationship
Phone
Name
Relationship
Phone

EMERGENCY MEDICAL INFORMATION

Allergies	Yes NoPlease make a selection.
Asthma	Yes NoPlease make a selection.
Diabetes	Yes NoPlease make a selection.
Heart Trouble	Yes NoPlease make a selection.
Convulsions/Seizures	Yes NoPlease make a selection.
Hemophilia	Yes NoPlease make a selection.
Fainting Spells	Yes NoPlease make a selection.

Explanation of any "yes" answers:

List any condition that may require special care or medication:

List any medications that your child is currently taking
(including inhalers, epi-pens, special instructions):

List any medications that will need to be administered during camp:

When will the medication need to be administered?

What is the Dosage?

List any details about the medication that the staff will need to know:

MEDICAL HISTORY

Date of most recent complete physical exam. Word A value is required.A value is required.Invalid format.

Any surgery, illness, allergy, or change in health status since last exam?
Yes No
Please make a selection.

If "yes" please explain:

Immunizations
Date of Last Innoculation

Tetanus	A value is required.A value is required.Invalid format.
Diptheria	A value is required.A value is required.Invalid format.
Polio	A value is required.A value is required.Invalid format.
Measles	A value is required.A value is required.Invalid format.
Mumps	A value is required.A value is required.Invalid format.
Rubella	A value is required.A value is required.Invalid format.
Pertussis	A value is required.A value is required.Invalid format.

Does the child have a history of:

Serious Injury	Yes No Please make a selection.
Surgery	Yes No Please make a selection.
Appendicitis	Yes No Please make a selection.
Nervous Condition	Yes No Please make a selection.
Chest or Lung Condition	Yes No Please make a selection.
Heart Problems	Yes No Please make a selection.
Stomach or Bowel Complications	Yes No Please make a selection.
Skin or Gland Complications	Yes No Please make a selection.
Kidney Complications	Yes No Please make a selection.
Ear or Eye Complications	Yes No Please make a selection.
Nose or Sinus Complications	Yes No Please make a selection.
Other Complications	Yes No Please make a selection.
If "yes" please explain:

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538 Emery Road, Dingmans Ferry, PA 18328 • 570-828-2319 • peec@peec.org