SECTION I: GENERAL INFO

Camper Name * Grade [entering in the fall]* Birth Date * Age * Sex *
Home Phone * Home Address * City * State * Zip Code *

SECTION II: GENERAL MEDICAL/ INSURANCE INFO

(Parent/guardian called first unless otherwise requested by parent/guardian)

Primary Physician/Pediatrician’s Name * Phone Number * Address * City * State * Zip Code *
Medical Insurance Co * Policy * I.D. *
Name of Insured * S.S.N. # for Policy Holder *
Relationship to Participant *

PLEASE INCLUDE A PHOTOCOPY OF YOUR CHILD’S HEALTH INSURANCE CARD.

SECTION III: EMERGENCY INFO

(Parent/guardian called first unless otherwise requested by parent/guardian)

Mother/Guardian * Work Phone *
Cell Phone *
Father/Guardian * Work Phone *
Cell Phone *

ADDITIONAL EMERGENCY NAMES AND PHONE NUMBERS MUST BE FILLED OUT OR THE FORM WILL BE RETURNED TO BE COMPLETED.

Name * Relation * Home Phone * Work Phone * Cell Phone *

Name * Relation * Home Phone * Work Phone * Cell Phone *

Name * Relation * Home Phone * Work Phone * Cell Phone *

To Mail - Print out form with Check and send to:
New York Fashion Accessories Camp (NYFAC) Jennifer Siletski PO Box 104 Millburn, NJ 07041