FALLSVIEW DAY CAMP
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Contact
Pricing/Dates
Camper Application
Staff Application
Camp Photos
Camp Photos 2017
Camp Photos 2018
Upload Medical FOrms & Immunization Records
As recommended by the NYS Department of Health, Fallsview has adopted the policy to require all campers to be up to date with their immunization as per the New York State Immunization Requirements for School Entrance/Attendance, available at
http://www.health.ny.gov/publications/2370.pdf
All campers must submit
form CH205 (click here to download)
filled out by and signed by their physician, along with Fallsview Emergency Form (
scroll down
) to be filled out by the parents of the child. For the safety of all campers, no child will be admitted to camp without having these forms on record. We thank you in advance for your understanding and cooperation.
*
Indicates required field
Medical forms must be received by June 1st and can be uploaded below or emailed to:
[email protected]
Camper's Name
*
First
Last
Upload Medical/Immunization Form
*
Max file size: 20MB
Comments
*
Submit Medical Forms
Emergency Form
Please fill out the emergency for EACH camper. After submitting the form, you can reload this page to fill it out for additional campers. For the safety of all campers, no child will be admitted to camp without having these forms on record. We thank you in advance for your understanding and cooperation.
Emergency forms must be in by June 10 and can be filled out below.
(If you are not able to fill out the form online, please
download it here
and mail or email it to:
Fayge Hirsch 2122 Ave N, Brooklyn N.Y. 11210
[email protected]
)
*
Indicates required field
Camper's Name
*
First
Last
Camper's Age
*
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Camper's Sex
*
Male
Female
Parent's Name
*
First
Last
Bungalow/Local Address
*
Line 1
Line 2
City
State
Zip Code
Country
Bungalow Phone
*
Father's Cell Phone
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Mother's Cell Phone
*
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Health History
(Please check all that apply, and add notes/dates/details in the NOTES section)
*
Frequent Ear Infections
Heart Defect/Disease
Convulsions
Diabetes
Bleeding/Clotting Disorders
Seizure Disorder
Allergies
(Please check all that apply, and add notes/dates/details in the NOTES section)
*
Hay fever
Ivy Poisoning
Insect Stings
Penicillin
Other Drugs
Food Allergy
OTHER (Provide details in NOTES)
Illnesses
(Please check all that apply, and add notes/dates/details in the NOTES section)
*
Chicken Pox
Measles
German Measles
Mumps
Asthma
Current Medications
*
Operations or serious injuries
(include dates)
*
Chronic or Recurring Illness
*
Other Disease
*
Notes & Other Allergies
*
Name of Person Filling Out Emergency Form (to serve as a signature)
*
Submit Emergency Form for 1 Camper