New Camper Application Camp Dates: August 20-27, 2023 New Camper Application General Camper Information Child's First Name * Child's Middle Name * Child's Last Name * Street Address * City * State/Province * Zip/Postal Code * Country * Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (DRC) Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (North Korea) Korea (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe 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: * Drop a file here or click to upload Choose File Maximum file size: 267.39MB If you are human, leave this field blank. Next