Submit Your Form Child's Name* First Last Child's DOB* MM slash DD slash YYYY Caregiver Phone Number*Caregiver Email* Location Seen*Center CityBala CynwydFishtownDelivery Method*Caregiver pick-up at officeFaxUS MailFax NumberAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Upload Document*Max. file size: 300 MB.Upload DocumentMax. file size: 300 MB.Upload DocumentMax. file size: 300 MB.Is this form for overnight camp?* Yes No Will your child be taking medications at camp?* Yes No Does your child or either parent have Sickle Cell Trait?* Yes No Since Your Child’s Last Checkup:Any injury or illness?* Yes No Chronic illnesses, hospitalizations, or surgeries?* Yes No New medications or supplements of any type?* Yes No Allergies to medications, insects or food?* Yes No Dizziness, passed out, experienced chest pain with exercise, or sudden death in a close relative < 50 years old?* Yes No History of hypertension or murmur?* Yes No Concussion, “knocked out”, unconsciousness or memory loss, seizure or severe/frequent headache?* Yes No Asthma, allergies, wheezing, difficulty breathing, chest pain?* Yes No Strain, sprain, fracture, joint pain or swelling?* Yes No Please allow 7 – 10 business days for processing. Complete the parent/caregiver section of the form(s) before downloading. Failure to do so will result in a delay. There is a $10 fee for each form, $15 for FMLA. Payment is due before the form is completed. Click Here to complete your form payment, or you can pay at the time of pick-up in our office. Δ