Friday, April 26, 2013

Camp Sav-A-Life - Free


                    Camp Save-A-Life

 (Youth ages 10-14)

“Make new friends while learning to keep your old friends safe!”


Camp Save-a-Life provides youth with the opportunity to learn valuable disaster preparedness techniques and leadership skills. Youth will become certified in CPR and First Aid, and most importantly, they will have fun while learning how to keep their families safe!


Monday, July 8, 2013 - Friday, July 12, 2013

Monday, July 15, 2013 - Friday, July 19, 2013

Monday, July 22, 2013 - Friday, July 26, 2013

Monday, July 29, 2013 - Friday, August 2, 2013

Monday, August 5, 2013 - Friday, August 9, 2013

Monday, August 12, 2013 - Friday, August 16, 2013




 9:00 am - 3:00 pm: Red Cross House

40th St. and Powelton Ave., Philadelphia, PA


Registration Deadline: Friday, June 7, 2013

*Please note: choose only ONE week for your child(ren) to attend


Space is limited. Applications are accepted on a first come, first serve basis.

The Camp is free of charge and participants will be provided with a snack and lunch daily.

You will become certified in CPR and First Aid

Please submit completed applications to:
Mike Kiley-Zufelt, Manger of Community Resiliency,
2221 Chestnut Street, Philadelphia, PA 19103
or via email to:














Last Name (Print):  ___________________________________________________________


First Name (Print): __________________________________________________ MI:______


Suffix: (e.g. JR, SR, etc.)______________               Nickname:_________________________


Age: ____________                                                  Date of Birth:______/_______/_____

                                                                                                           month         day            year


Gender:  Female    Male                                      T-shirt size: XS    S    M   L    XL


Home Address: ______________________________________________________________


City: ________________________________ State: __________ Zip Code: ______________


Home Phone: _________________________ Cell Phone: ____________________________


Email: _____________________________________________________________________


Grade:  (in September 2012)         4TH           5TH           6TH           7TH          8TH          9TH            


School Name:_________________________________________________________________


City: _________________________________ School District: _________________________


Camp Week: □ July 8th – 12th     □ July 15th – 19th     □ July 22nd – 26th      □ July 29th – August 2nd

                      □ August 5th - 9th       □ August 12th - 19th






Name:____________________________________ Relation: ___________________________


Address: _____________________________________________________________________


City: ________________________________ State: __________ Zip Code: ______________


Home Phone: ______________________________ Cell Phone: _________________________


Work Phone: ______________________________ Employer: __________________________




Name:____________________________________ Relation: ___________________________


Address: _____________________________________________________________________


City: ________________________________ State: __________ Zip Code: ______________


Home Phone: ______________________________ Cell Phone: _________________________

Work Phone: ______________________________ Employer: __________________________


Additional Emergency Contact


If you (the parent/guardian) cannot be reached in the case of an emergency, please list an additional person whom we can contact. If you can’t be reached, this individual may be asked to make medical decisions for your child on your behalf.

Name:____________________________________ Relation: ___________________________


Home Phone: ______________________________ Cell Phone: _________________________


Work Phone: ______________________________ Employer: __________________________





Please fill out the following questions to the best of your knowledge. Please indicate “no” in the space if the participant has none of the conditions listed in that question.


1.    Medications (Please include prescription and over-the-counter medications.)




2.    Allergies (Please list any allergies to medications, bug bites/stings, food, etc.)




3.    Medical conditions in which we should know about (i.e. asthma, diabetes, heart disease, recent surgery, past/present seizures.)




4.    Family history of diseases (in case your child displays any symptoms.)




5. Are all immunizations up to date?   Yes        No




Note: No one will be excluded from participation due to the lack of health insurance.


Name of Insured (name on the card):________________________________________________


Company or Plan:___________________________________Phone_______________________


Address: ______________________________________________________________________

City:________________________    State: ____________________  Zip: __________________


Policy # :__________________________________    Group # :__________________________





This plan is considered (please check on e of the following):

q  HMO (Health Maintenance Organization

q  PPO (Preferred Provider Organization                Other: Please specify: ________________

Participant Agreement and Parental (Guardian) Waiver/Consent


I, the undersigned, give my permission for the below named youth to attend the 2013 American Red Cross Camp Save-A-Life at the Red Cross House, 40th and Powelton Sts., Philadelphia, Pennsylvania from: □ July 8th – 12th  □ July 15th – 19th  □ July 22nd – 26th  □ July 29th – August 2nd

                                □ August 5th - 9th       □ August 12th - 19th.

 In the event of an emergency, if neither parent/guardian nor the person(s) on emergency contact section can be reached, I hereby authorize the Red Cross Adult Staff, and/or hospital doctors/personnel (if participant needs hospital care) to take any action deemed necessary for the best interests of the below named youth for whom I am responsible.


I, the undersigned, know that participation in certain activities of the American Red Cross Camp Save-A-Life could be potentially hazardous.  I will not participate in any activities of the Camp Save-A-Life unless physically able.  I certify that my physical condition will enable me to participate in the Camp Save-A-Life.  Further, I agree to abide by any decision of the staff relative to my ability to participate in any activity of the Camp Save-A-Life.


I, the undersigned, give my permission for my daughter/son to administer his/her own prescription and /or non-prescription medication that s/he will bring to the American Red Cross Camp Save-A-Life.  I understand that the American Red Cross and/or Red Cross staff will not be responsible for dispensing, tracking, or administering these medications.


I, the undersigned, hereby agree to abide by the rules and regulations of the American Red Cross and elect to participate in the American Red Cross Camp Save-A-Life at my own risk, and in consideration for being allowed to participate in the American Red Cross Camp Save-A-Life, I do hereby release and discharge the American Red Cross, its assignees, officers, agents, employees, and officials from any and all liability (including, without limitation, personal injury and property damage) that may be incurred by me (or my minor child) as a result of participation in the American Red Cross Camp Save-A-Life, except where the same is caused by the willful misconduct of the American Red Cross.


Participant Name:______________________________________________________________

Participant Signature:___________________________________________________________

Participant Phone Numbers:_________________________home_____________________cell



Parent/Guardian Name:__________________________________________________________

Parent/Guardian Signature:_______________________________________________________

Parent/Guardian Phone Numbers:_____________________home_____________________cell


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