Georgia PKU Connect, Inc. · Camp Connect 2022 Registration

Registration is $50 per camper. Please select the checkbox, then the number of people registering for camp (including you) from the drop down menu. *	Quantity
$50

Family Information

Name (primary contact for family):

*

First Name

Last Name

Phone Number:

*

Email:

*

Verify Email

*

Address:

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

County (Enter Georgia County of Residence or "Out of State"):

*

Is your family interested in a low protein cooking class?

*

Yes

No

Total number of people attending from your family:

*

(PLEASE INCLUDE YOURSELF/PRIMARY CONTACT IN TOTAL NUMBER)

Family Lodging Needs:

Please select all that apply.

We are sensitive to loud noises at night/morning

We have mobility needs (accessibility accommodations)

We go to bed late

We get up early

We sleep in

We would like to lodge near a specific family (or families)

If applicable, please list the family or families you would like to lodge near:

Please add any additional details about your lodging needs:

Family Insurance

Form of Payment

*

Self Pay

Private Insurance

Medicaid

Medicare

SCHIP

TRICARE

VHA

IHS

Medicaid/Medicare/Other Govt Health Program Number (if applicable):

State (if Medicaid/Medicare):

CIDC Number (if Medicaid):

Insurance Company Name (for Private Insurance):

Member ID # (for Private Insurance):

Group # (for Private Insurance):

Insurance Company Phone Number:

In case of emergency please notify:

*

Please enter full name (first and last)

Emergency Contact Phone Number:

*

Relationship (Mother, Father, Grandmother, Aunt, Friend, etc.):

*

Acknowledgement

*

I certify all insurance information provided is complete and accurate.

Camper #1 Details

(PLEASE INCLUDE YOURSELF AS A CAMPER)

Camper #1 Name:

*

First Name

Last Name

Camper #1 Birthdate:

*

(mm/dd/yyyy)

Camper #1 Gender

Camper #1 T-Shirt Size:

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Does camper #1 have any diagnosis or medical concerns?

*

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Does camper #1 have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A?

*

Is there anything else we should know about this individual to make the weekend great?

Camper #2 Details

Camper #2 Name

*

First Name

Last Name

Camper #2 Birthdate

*

(mm/dd/yyyy)

Camper #2 Gender

Camper #2 T-Shirt Size

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Does camper #2 have any diagnosis or medical concerns?

*

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Does camper #2 have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A?

*

Is there anything else we should know about this individual to make the weekend great?

Camper #3 Details

Camper #3 Name

*

First Name

Last Name

Camper #3 Birthdate

*

(mm/dd/yyyy)

Camper #3 Gender

Camper #3 T-Shirt Size

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Does camper #3 have any diagnosis or medical concerns?

*

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Does camper #3 have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A?

*

Is there anything else we should know about this individual to make the weekend great?

Camper #4 Details

Camper #4 Name

*

First Name

Last Name

Camper #4 Birthdate

*

(mm/dd/yyyy)

Camper #4 Gender

Camper #4 T-Shirt Size

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Does camper #4 have any diagnosis or medical concerns?

*

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Does camper #4 have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A?

*

Is there anything else we should know about this individual to make the weekend great?

Camper #5 Details

Camper #5 Name

*

First Name

Last Name

Camper #5 Birthdate

*

(mm/dd/yyyy)

Camper #5 Gender

Camper #5 T-Shirt Size

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Does camper #5 have any diagnosis or medical concerns?

*

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Does camper #5 have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A?

*

Is there anything else we should know about this individual to make the weekend great?

Camper #6 Details

Camper #6 Name

*

First Name

Last Name

Camper #6 Birthdate

*

(mm/dd/yyyy)

Camper #6 Gender

Camper #6 T-Shirt Size

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Does camper #6 have any diagnosis or medical concerns?

*

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Does camper #6 have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A?

*

Is there anything else we should know about this individual to make the weekend great?

Camper #7 Details

Camper #7 Name

*

First Name

Last Name

Camper #7 Birthdate

*

(mm/dd/yyyy)

Camper #7 Gender

Camper #7 T-Shirt Size

*

Youth Small

Youth Medium

Youth Large

Adult Small

Adult Medium

Adult Large

Adult XL

Adult 2XL

Adult 3XL

Does camper #7 have any diagnosis or medical concerns?

*

(multiple answers can be selected)

No

PKU

FAOD

Other

If other please name:

Does camper #7 have any allergies (medicinal, dietary, environmental) or other dietary restrictions? If no, write N/A?

*

Is there anything else we should know about this individual to make the weekend great?

Optional Donation

Would you like to make a donation to Georgia PKU Connect (in addition to your registration fee) to support Camp Connect, including camper scholarships?

*

Yes, I would like to make an additional donation.

No, not at this time.

Select or enter custom donation amount:

$250

$100

$50

$25

$

We're excited you're coming to camp!

After submitting your/your family's registration, you will receive a confirmation email. This email will have a link to view the required Georgia PKU Connect/Camp Twin Lakes Release Form. We will have a copy for you to sign at check-in on September 9th.

If you have questions at any time, feel free to email us at camp@georgiapku.org.

Please review the information entered above and then click submit to complete your camp registration payment.