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2022 Staff Information Form
This form must be completed and signed by the staff member and parent/guardian (if required by age)
First Name
*
Last Name
*
Camp Location
*
Choose One
County College of Morris
St. Elizabeth University
Bryn Athyn
Cabrini University
Cedar Crest College
Del Val University
Friends Select
LaSalle College High School
Montgomery County Community College
Notre Dame
Phelps School
Plumstead Christian
St. Aloysius Academy
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Cell Phone
*
Home Phone
Email Address
*
Attach Immunization Record
Current Medications:
+
-
Reaction to Medications:
+
-
Allergies:
+
-
Insurance Company
Policy No.
If you have current clearances, please upload here
Emergency Contact Information
First & Last Name
*
Relationship
*
Phone Number
*
Staff Members Signature:
*
clear
Parent/Guardian's Signature (if required by age)
clear