Summer Camp 2024 Camper Registration and Health Forms - editing from scratch to work out kinks

Summer Camp 2024 Camper Registration and Health Forms - Important Instructions

PLEASE READ THROUGH THE INSTRUCTIONS COMPLETELY - DO NOT SKIP!!

Please complete the google form to complete registration for your child for People of God Summer Camp 2024. The health form and waivers are also included in this online form and must be completed. Please be sure to have all the needed medication names, medical history, vaccination dates, insurance information, credit card, etc. on hand before beginning the form if possible. Payment is due before form can be submitted!

Due to the conditional formating of this form! It will work best if completed from top to bottom (the first question to the second question and so forth - except when clicking save). Please do not jump around the document. Answer the questions one at a time and in order, and you will save yourself many headaches. You can always come back and reread this instruction page.

*** After completing the basic contact info and after you answer the "email address" question please take a moment scroll to the bottom of the form and click "Save" this will allow you to pick up where you left off, should you be unable to finish the form. If you do not hit SAVE periodically, your progress will be lost. After hitting save you will be prompted with a Jotform popup (it may look like the image below if you have not filled out a jotform before). You do not need a jotform account to save the document simply choose the option that sends a link to your email for easy access to the form. This is in small blue print and says "Skip Create an Account". You can then enter the email that you want Jotform to send the access link to. Make sure to check your junk mail if you do not see it immediately. Upon the completion of more questions, make sure to hit "Save" once more before exiting the form. And do not forget to hit "Submit" at the very end of the form.

Proceed through the registration until you see the screen below. Your responses have not been submitted until you see the following screen!!!

If you have any questions, please email pogcamp@gmail.com.

Joel Pepmeyer, Seth Porterfield, Katie Grella, and Beth Mayer

Does your child have any allergies? (medicine, environmental, food, etc.)*

YesNo
Allergy Information
Medication Allergies (list names of drugs and reactions)
Food Allergies please list food, reaction, and treatment needed
Environmental/Insect Allergies (describe reaction and treatment needed)
Does your child carry an epipen?

YesNo
Additional Allergy Information
Please list your child's typical initial symptoms when they have had an allergic reaction in the past (for example, hives, nausea, vomiting, swelling, etc.)
Has your physician given your child a written allergy action plan? (The Camp Nurses will be requesting a copy)

YesNo
Have your child been seen in the ER or hospitalized for an allergic reaction in the past year? (If yes, how many times?)

Asthma
Does your child have asthma?*

YesNo
Does your child carry a rescue inhaler (for asthma or any other reason)?*

YesNo
What are the triggers for your child's asthma (for example, animals, pollen, illnesses, foods, etc.)?
Please list your child's typical initial symptoms when suffering an asthma attack (cough, shortness of breath, wheezing, etc.)?
How many times per month does your child use a rescue inhaler or nebulizer (albuterol, xopenex, etc.)
Has your child been seen in the ER or hospitalized for asthma in the past year? (If yes, how many times?)
Please list any additional information/concerns you have about your child's asthma management at camp.

Medications

Please list all prescription and any over the counter medications your child takes. Don't forget to include inhalers and/or epipen. You must include the following: MEDICATION NAME, DOSE (total # of pills/dose and mg/dose), FREQUENCY, TIMES NORMALLY TAKEN AT HOME, REASON, and IF THE MEDICATION SHOULD BE TAKEN AS NEEDED. Please simply list N/A (for Medication #1) if you do not have medication needs.
All prescription medication must be brought to camp in a current and correctly labeled prescription bottle(s) and all over the counter medication must be in its original packaging!!
Medication #1 (name, dose (#of pill(s) and mg). frequency, time normally taken at home, reason, if only be taken as needed) Example: Zyrtec 10 mg daily, 8pm seasonal allergies*
Medication #2 (name, dose (#of pill(s) and mg). frequency, time normally taken at home, reason, if only be taken as needed) Example: Zyrtec 10 mg daily, 8pm seasonal allergies
Medication #3 (name, dose (#of pill(s) and mg). frequency, time normally taken at home, reason, if only be taken as needed) Example: Zyrtec 10 mg daily, 8pm seasonal allergies
Medication #4 (name, dose (#of pill(s) and mg). frequency, time normally taken at home, reason, if only be taken as needed) Example: Zyrtec 10 mg daily, 8pm seasonal allergies
Medication #5 (name, dose (#of pill(s) and mg). frequency, time normally taken at home, reason, if only be taken as needed) Example: Zyrtec 10 mg daily, 8pm seasonal allergies
Medication #6 (name, dose (#of pill(s) and mg). frequency, time normally taken at home, reason, if only be taken as needed) Example: Zyrtec 10 mg daily, 8pm seasonal allergies
Additional Medications

If you will be bringing more than six medications to camp, please email this additional information to Sarah Gold, camp nurse. Email address is sjg3232@gmail.com
Illness Protocol
If your child needs to be picked up from camp due to serious symptoms/illness and YOU are NOT able to pick up your child, what arrangements do you have in place for another adult (over the age of 18) to have permission to come pick up your child? Please include the adult's name and phone number.*
Consider Scrolling Down and Clicking "Save" at this point - your progress will be saved to the link that Jotform previously sent you via email

Insurance Information

If you do not have traditional health insurance , put NA in the required boxes and explain in the "any other info we should know" box below
Policy Holder *
ID#*
Insurance Carrier*
Group#*
Child's Physician*

First NameLast Name
Child's Physician's Phone Number*
Please enter a valid phone number.
Child's Dentist*

First NameLast Name
Child's Dentist's Phone Number*
Please enter a valid phone number.
Any other info we should know?
Electronic Signature

By electronically signing your name below, you are verifying that all information included in this form and heath record is accurate to the best of your knowledge. Any changes in information prior to arrival at Summer Camp will need to be communicated with the directors and/or the nurse via the email address pogcamp@gmail.com . I also understand that all prescription medication must be brought to camp in a current and correctly labeled prescription bottle(s) and all over the counter medication must be in its original packaging.
Sign Below

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Payment

(The cost of camp is $420 per camper (for 6th graders: $30 additional for adventure trip), please only use the third option if it truly applies as available funds for financial aid are limited)
Which applies most? "At camp my child will be a..." or "I ..."*

3rd-5th Grade Graduate (following the 23-24 school year) - $4206th Grade Graduate (following the 23-24 school year) - $450I am in need of financial assistance; I have communicated directly with Joel Pepmeyer and have arranged for an alternate form of payment (I am paying $0 at this time)I have (or someone on my behalf has) already paid for camp, by taking advantage of the "Gift of Camp" promotion during the Christmas season.I plan to mail a check ASAP for the applicable amount (Please place your camper's name in the memo line and make the check/money order payable to POG Summer Camp. Mail it to: POG Summer Camp c/o Joel Pepmeyer 316 3rd Street, Aspinwall PA 15215)
My Products
prevnext( X )
3rd - 5th Grade Graduate (following the 23-24 school year)
$420.00 Quantity

6th Grade Graduate (following the 23-24 school year)Includes price for the adventure trip that takes place on the Thursday afternoon of camp.
$450.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Registration Information

Camper Health Form Information

Consider Scrolling Down and Clicking "Save" at this point - your progress will be saved to the link that Jotform previously sent you via email

Allergy Information

Asthma

Immunization Information

Medications

Additional Medications

Illness Protocol

Consider Scrolling Down and Clicking "Save" at this point - your progress will be saved to the link that Jotform previously sent you via email

Insurance Information

Electronic Signature

Waivers

Payment