Camp Janus 2019 is from Thursday, May 23 - Sunday, May 26


Camp Janus 2019 

Application Deadline: Friday, May 10, 2019.


Camper Information
To be completed by a parent or guardian only
Name *
Name
Knowing your child's burn history helps us provide the best camp experience possible for your child
Date of Injury
Date of Injury
First Degree, Second Degree, Third Degree, Heat, Electrical, Radiation, Chemical
Birthday *
Birthday
T-Shirt Size
Please check your t-shirt size. We will try to accommodate your choice.
Address *
Address
Please list ANY allergies your camper may have: medications, food, insects, etc.
If your child requires an EpiPen, please provide it. Camp Janus is UNABLE to provide prescribed medications (such as EpiPens) for campers.
Please list ALL medications, dosages, and times the medication is given. If your child has an EpiPenĀ®, please send it with them to camp.
List any medications that require refrigeration
If medically indicated, it is OK to give my child: (check all that apply)
Please list any significant physical, cognitive, or behavioral conditions that may affect your child's experience at camp. This could be conditions such as Down Syndrome, ADHD, anger management issues, depression, heart conditions, broken bones, shunts, etc.
Does your child wear pressure garments, splints, or require dressing changes?
My child will travel to camp:
Please list your preferences for cabin mates. Cabin mates must be within 3 years of your age, and must be of the same sex. Maximum of 2 names allowed. CABIN MATES CANNOT BE GUARANTEED, but we will try our best.
Parent or Guardian Information
To be completed by a parent or guardian only
Parent or Guardian Name *
Parent or Guardian Name
Parent or Guardian Home Phone *
Parent or Guardian Home Phone
Parent or Guardian Mobile Phone Number *
Parent or Guardian Mobile Phone Number
If possible, I prefer Camp Janus contact me with camp information:
Emergency Contacts
To be filled out by parent or guardian only. Please provide multiple names of emergency contacts. We will only notify the emergency contact if there is an emergency at camp and YOU ARE NOT AVAILABLE.
Emergency Contact 1 *
Emergency Contact 1
In case of emergency, please contact this person.
Friend of Family, Aunt, Uncle, Grandparent, etc.
Emergency Contact 1 Phone Number *
Emergency Contact 1 Phone Number
Number to reach this contact person in case of emergency.
Emergency Contact 2
Emergency Contact 2
In case of emergency, please call this person.
Friend of Family, Aunt, Uncle, Grandparent, etc.
Emergency Contact 2 Phone Number
Emergency Contact 2 Phone Number
Number to reach this contact person in case of emergency.
Tell Us How You Discovered Camp Janus: