Pennsylvania Professional Fire Fighters Association

Burn Camp 2010

Pre-Registration Form

Please Print All Information

Return this form by A.S.A.P.

Last Name _______________________________  First Name _____________________  Sex_____

Addresses ____________________________________  County ____________________________

City ____________________________________  State ________  Zip ____________  Age ______

Day time phone number (____)__________________  Home phone number (_____)____________ 

Date of birth _____ / _____ / _____                             Grade completed June 2009 ________________

Father’s name _____________________________  Mother’s name _______________________

Special needs  To Help with camp program planning dose your child require?

            Special Diet?                                                                             Yes ______  No ______

            Bandages for open wounds?                                                       Yes ______  No ______

            Does your Child presently wear pressure garments?                      Yes ______  No ______

Please list any special needs (i.e. Doesn’t dress self, cannot feed self, etc.)

____________________________________________________________________________________

Dose your child have any special fears or concerns? (thunder storms, bugs darkness, etc.)

____________________________________________________________________________________

Upon receipt of your registration form, we will send you additional information such as medical forms,

Confirmation, and directions to camp.  Return forms to:

David W Schmidt, Vice President

Pennsylvania Professional Fire Fighters Association

220 South 16^th Street

Allentown, PA 18102

                                    For questions, e-mail Dschmidt@ppffa.org