Camper Application – Connecticut Burns Care Foundation

Camp Dates: August 20-27, 2023

New Camper Application

Child's First Name *

Child's Middle Name *

Child's Last Name *

Street Address *

City *

State/Province *

Zip/Postal Code *

Country *

Home Telephone *

Mother's Full Name *

Mother's Phone Number in case of Emergency: *

Mother's Email Address *

Father's Full Name *

Father's Phone Number in case of Emergency: *

Father's Email Address *

Please notify if neither Mother nor Father are Available in an Emergency - Please Include Full Name, Relationship to Child and Phone Number/s! *

Child's Date of Birth *

Child's Age *

Adult T-Shirt Size: *

XS, S, M, L, XL, XXL, etc.

Child's Gender? *

Female

Male

Dietary Restrictions?

(vegetarian, food allergies, religious restrictions, etc.)

Date of Burn Injury *

Date of Discharge from Hospital *

Hospital/s Where Treated / Providing Burn Care: *

How did burn occur? *

Percentage & Depth of Burns: *

Areas of body burned? *

Name of Primary Care Physician *

Phone of Primary Care Physician *

Full Address of Primary Care Physician *

Name of Burn Care Physician *

Phone of Burn Care Physician *

Address of Burn Care Physician *

Please Upload a Current Photo of Your Child: *

Maximum file size: 267.39MB