Corning Joint Fire District
Corning, NY
Town of Corning
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CJFD Fire Experience Camp Long Form
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Jr Fire Camp Application (Long)
"
*
" indicates required fields
Applicant's Information
Applicant's Name
*
First
Last
Applicant's Current Age
*
Is the Applicant a Male or Female?
*
Male
Female
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Email
*
Grade Entering August 2025 School Year?
*
Parent/Guardian's Information
Parent/Guardian Name
*
First
Last
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Work Phone
Cell Phone
*
Email
*
Emergency Contact's Informaiton
Emergency Contact Name
*
First
Last
Cell Phone
*
Emergency Contact Relationship to Camper
Only the following people may pick my child up from the Fire Camp:
*
Add
Remove
Write none if no one besides you can pick your child up.
Insurance Information
Is the Participate covered by family medical/hospital insurance?
*
Yes
No
Carrier or Plan Name
*
Group #
*
Insurance Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Insurance Phone
*
Medication Allergies:
*
List all known. Describe reaction and management of the reaction.
Food Allergies:
*
List all known. Describe reaction and management of the reaction.
Other Allergies:
*
List all known. Describe reaction and management of the reaction.
List all health concerns, limitation or restrictions, and medications for your child
*
Participant Does NOT Eat
*
Red Meat
Pork
Dairy Products
Seafood
Eggs
Other
Other Food
Participant's Behavior
Use this space to provide any additioanl information about the participant's behavior and physical, emotional, or mental health about which the camp should know.
Name of Family Physician
Physician's Phone
*
Attendance Information
Will your child be attending the entire week program?
*
If no, select the dates your child will attend
Yes
No
Check the box of the dates your child will attend
*
You must pay for the full week, even if you are not attending all days.
This camp will not be prorated.
Wednesday: July 26, 2024
Thursday: July 27, 2024
Friday: July 28, 2024
Select T-shirt Size
*
T-shirt is included in application fee. If registering more than one child, indicate number of shirts if necessary.
Youth Small
Youth Medium
Youth Large
Youth X-Large
Adult Small
Adult Medium
Adult Large
Adult X-Large
Consent
*
During the fire fighter experience camp, campers will participate in physical activities that have the potential for injury. While every precaution is made to ensure the safety of everyone involved and Emergency Medical Care Providers will be on hand throughout the entirety of the camp, there is a slight risk of injury associated with some of the exercises associated with the camp.
I acknowledge the risks associated with allowing my child/children to participate in the Fire Fighter Experience camp and consent to allow my child/children to participate in the Fire Fighter Experience camp.
Receipt email address:
Yes, I consent to having you email me an email receipt of this form and to email regarding the camp.
Would you like a copy emailed to you?
Signature
Phone
This field is for validation purposes and should be left unchanged.
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