EMS Symposium 2019 Youth and Teen Camp Student Information Form

Thank you for registering your child for the 2019 Virginia EMS Symposium Youth and Teen Camps. Please complete the form below as soon as possible, but no later than October 25, 2019. Please contact Adam Harrell via email (adam.harrell@vdh.virginia.gov) or phone (804-888-9101).

Symposium Youth and Teen Camp Student Information Form

Childs Name*
First Middle Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Which Camp is your Child Attending?*
Youth Camp - ages 8 to 12 | Teen Camp - ages 13 - 17
Medications Taken by the Above Named Person*
If no medications are taken, please type "No medications taken"
Allergies to Food or Medications, Etc*
If no allergies to food or medication, please type "No known allergies"
Other Information or Instructions Need to Know:
Any information you feel the camp instructors should know (i.e. does your child have a nickname they prefer).
Insurance Information or Copy of Card
Please enter the insurance information (Insurance company name, policy number, group number) or provide a copy of the card
Copy of Insurance Card
Drop files here or
Emergency Contact Information
Emergency Contact 1*
First Last
Relationship of Emergency Contact 1*
Phone (onsite preferred) for Emergency Contact 1*
Emergency Contact 2*
First Last
Relationship of Emergency Contact 2*
Phone (on site preferred) of Emergency Contact 2*
Consent to Medical Treatment*
I agree to the medical treatment and/or attention agreement to my child listed above.
If my child should require medical attention or treatment I give permission for Virginia EMS Symposium Youth and/or Teen Camp Instructors to agree to the necessary treatment for my child in my absence.
Name of Person Completing This Form*
First Last
Email of Person Completing This Form*
Enter Email Confirm Email
Shirt and Lunch Order
Lunch Selection (for Friday)*
Lunch Special Requests (for Friday)
Lunch Special Requests (for Saturday)
Included with the Youth/Teen Camp Registration is a lunch cruise for the children on the Spirit of Norfolk. Their lunch will be buffet style, but please let us know if there are any special requests. We will do what we can to accommodate, but cannot guarantee all requests will be honored. All allergies will be accommodated.
Are you interested in being a parent chaperone for the lunch cruise (Saturday)?*
We have limited availability for parent chaperone(s) on the lunch cruise. There is no cost for this opportunity. Interested chaperones will be contacted prior to the symposium to confirm your attendance as a chaperone.
Parent Chaperone on Lunch Cruise (Saturday) if interested
First Last
Email for parent chaperone (Saturday) if interested
T-Shirt Size*
We will be ordering 2 shirts per child, so please make sure the size you request is correct

Symposium Youth and Teen Camp Student Information Form

Emergency Contact Information

Shirt and Lunch Order