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Pennsylvania Professional Fire Fighters Association
Burn Camp 2010
Pre-Registration Form
Please Print All Information
Return this form by A.S.A.P.
Last Name _______________________________ First Name _____________________ Sex_____
Addresses ____________________________________ County ____________________________
City ____________________________________ State ________ Zip ____________ Age ______
Day time phone number (____)__________________ Home phone number (_____)____________
Date of birth _____ / _____ / _____ Grade completed June 2009 ________________
Father’s name _____________________________ Mother’s name _______________________
Special needs To Help with camp program planning dose your child require?
Special Diet? Yes ______ No ______
Bandages for open wounds? Yes ______ No ______
Does your Child presently wear pressure garments? Yes ______ No ______
Please list any special needs (i.e. Doesn’t dress self, cannot feed self, etc.)
____________________________________________________________________________________
Dose your child have any special fears or concerns? (thunder storms, bugs darkness, etc.)
____________________________________________________________________________________
Upon receipt of your registration form, we will send you additional information such as medical forms,
Confirmation, and directions to camp. Return forms to:
David W Schmidt, Vice President
Pennsylvania Professional Fire Fighters Association
220 South 16th Street
Allentown, PA 18102
For questions, e-mail Dschmidt@ppffa.org
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