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Summer Camp 2025 Application

August 22-24

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email *

Phone *

(###)

###

####

Children Name and Date of Birth *

Emergency Contact *

First Name

Last Name

Email

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).

Medical problem

Treatment

Should paramedic by called?

Yes

No

CheckboxYou or a family member presently being treated for an injury or sickness, or taking any form of medication for any reason?

Yes

No

If yes, explain:

You or a family member allergic to any type of food or medication?

Yes

No

If yes, explain:

You or a family member require a special diet?

Yes

No

If yes, explain:

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment. Authorization in Case of Emergency: I hereby give permission to the hospital, physician, or dentist to provide proper emergency treatment for the undersigned or for the child named above. This includes the administration of injections, anesthesia, and/or emergency surgery as deemed necessary by the condition at hand. I understand that every reasonable attempt will be made to contact me prior to such treatment.

Please list any additional info here

Date *

MM

DD

YYYY

By Selecting Yes, you confirm your consent and verify that the information provided is accurate. No signature is required. *

Yes

No

Your ACOP Camp application has been received. Thank you!

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Pasadena, CA 91107

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Phone
(626) 351-9631

Email
maryagulian@paznaz.org

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