Grapefruit Testing: Camp Testing
Please fill this out to ensure you will be able to test and attend summer camp this summer. This form is for both campers and/or staff.
Please list your Camp Name
Name of Camper or Staff Member (the individual being tested)
First Name
Last Name
Gender
Please Select
Male
Female
Non-Binary
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address (mailing address to ship pre-arrival kits to if your camp is offering this)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
Name of Insurer (if you don't have insurance please type NONE)
*
Group ID Number
*
Insurance Subscriber Name
*
First Name
Last Name
Insurance Subscriber Phone Number
*
Please enter a valid phone number.
Subscriber Date of Birth (Note: this information must be filled in correctly to ensure you are able to get tested in a timely manner and attend camp on time)
*
-
Month
-
Day
Year
Date
Relationship to Insurance Subscriber (parent, self, etc)
*
Subscriber/Member ID number
*
Responsible Party Full Name (almost always the same person as your subscriber. If it is not the same person as above please note their name, Date of birth, and relationship to them below
Social Security Number (securely stored in electronic health record system) NOTE: this is needed for those without insurance for compliance with the CARES Act)
Please Upload a Photo of your front and back of insurance card
*
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