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Programs & Services
News & Events
Volunteer
Careers
Contact
Donate

Register for Camp Kelly 2022

Camper Name*
Camper Date of Birth*
MM slash DD slash YYYY
Camper Gender*
Camper T-shirt Size*
Camper Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent Email*
Parent Phone*
Parent Name*
First Last
Parent 1 Emergency Contact
Parent 1 Address Same As Child
- Parent 1 Address Same As Child
Name
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Parent 2 Emergency Contact
Parent 2 Address Same As Child
- Parent 2 Address Same As Child
Name
Phone Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Emergency Contact
Name*
Phone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Health History

Does or has the camper:
Ever been hospitalized or had surgery?*
- Yes
- No
Had a recent, recurring, or chronic illness, injury, or infectious disease?*
- Yes
- No
Had asthma, wheezing, or shortness of breath?*
- Yes
- No
Had seizures, fainting, or dizziness?*
- Yes
- No
Have problems with diarrhea/constipation, or bedwetting?*
- Yes
- No
Have problems with falling asleep/sleepwalking?*
- Yes
- No
Ever had back/joint problems or skin problems?*
- Yes
- No
Have diabetes?*
- Yes
- No
Traveled outside the country since December of 2021? *
- Yes
- No
If female, have problems with periods/menstruation?*
- Yes
- No
Ever been treated for attention deficit disorder (ADD), attention deficit/hyperactivity disorder (ADHD), emotional or behavioral difficulties, or an eating disorder?*
- Yes
- No
During the past 12 months, seen a professional to address mental and emotional health concerns or had a significant life event that continues to affect the participant's life (abuse, death of a loved one, divorce, adoption, foster care, new sibling, survived a disaster)? *
- Yes
- No
Been vaccinated against COVID 19?*
- Yes
- No
Explain if a yes is checked for any of the Health History questions
Insurance
Is the patient covered by family medical/hospital insurance?*
- Yes
- No
Company*
Group Number*
Policy / Member Number
Policy Holder*
Healthcare Provider
Physician Name*
Physician Phone*
Cabin Request 1:*
Cabin Request 2:*
Food Restrictions*
- Lactose
- Gluten
- Pork
- Vegan
- Vegetarian
- Other
Please Explain
Allergies (List any allergy and reaction)*
Medications (Please list any medication the child will be taking at camp. We will follow up with a form to be filled out by your doctor.)*
*Note: All authorizations will be done on Move In Day.
Select Week*
- Week 1: July 10-15
- Week 2: July 24-29
- Week 1 & Week 2
Total
$0.00
CAPTCHA
Credit Card
Card Details
Cardholder Name
If you have questions about registration, please contact Alexis Featherman at (570) 344-9882 or at afeatherman@uncnepa.org.

United Neighborhood Centers of Northeastern Pennsylvania
425 Alder Street
Scranton, PA 18505
Phone: 570-346-0759
Fax: 570-207-4242

If you are seeking emergency assistance for rent, housing, food, or utilities, please call UNC’s Community Services Department at 570-343-8835.

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