Tadpoles Camp Registration

Please fill out the form below to register your child for summer day camp at PEEC.

BE SURE TO SELECT THE CORRECT WEEK(S) AND EXTRA SERVICES.

If you have a coupon code, please enter it below.

NOTE: REGISTRATIONS RECEIVED AFTER FRIDAY OF THE UPCOMING WEEK WILL HAVE A $25 FEE ADDED TO THE REGISTRATION PRICE.

You may select multiple weeks for your child. Be sure to choose the correct camp week(s) and full or half day!

 
EXTRA SERVICES
$50 per child, per week, per service. Make sure the quantity of each extra service selected matches number of camp weeks selected

Make sure number of bagged lunches selected matches number of camp weeks selected!

Make sure pick up/drop off quantity matches number of camp weeks selected!

Make sure pick up/drop off quantity matches number of camp weeks selected!

CAMPER INFORMATION
Male Female  
PARENT/GUARDIAN INFORMATION
PICKUP AUTHORIZATION
EMERGENCY INFORMATION

Please list the NAME and NUMBER of your child's personal physician. If they do not have one, simply enter N/A.

Please enter the provider of your health insurance provider and your policy number. If you do not have health insurace, simply enter N/A in both fields.

EMERGENCY MEDICAL INFORMATION
Yes No  
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Please list any condition which may require special care or medication.

Please list any medication(s) that your child is currently taking (includes inhalers, epi-pens, special instructions).

Please list any medications that will need to be administered during camp.

Please list the time(s) the medication(s) will need to be administered and the dosage(s).

Please list any other details about the medication that the staff will need to know.

MEDICAL HISTORY

Please provide the date of your child's most recent physical examination (month/year).

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Immunizations
Does Your Child Have a History of:
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PARENTAL STATEMENT
I agree to the terms of enrollment and give permission for my child to participate in all program activities. I understand every effort will be made to contact me. In the event I cannot be reached, I give permission for Pocono Environmental Education Center to secure proper medical treatment. I request that measures (including hospitalization, anesthesia, surgery, or injections medication) be instituted for my child without delay as judgement of medical personnel dictates. CHECK "ACCEPT," ENTER THE TEXT SHOWN IN THE CAPTCHA, THEN CLICK "NEXT" TO CONTINUE TO PAYMENT.
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