Arizona Children's Burn Camp

CAMP COURAGE
"Celebration of the human spirit"

LIT Application


Basic Info
LIT status
First Year LIT Returning LIT
Email
* First Name
* Last Name
Gender
Date of Birth
T-Shirt Size
Is camper bilingual (English/Spanish)?
Yes No
Address 1
Address 2
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
Employer
Position
Address 1
Address 2
City
State
Zip Code
Supervisor"s Name
Phone
Emergency Contact Information

* Primary Contact Name
* Primary Contact Phone
* Alternate Contact Name
* Alternate Contact Phone
* Physician Name
* Physician's Phone Number
* Allergies (food, medical, etc)
List any medications you are taking
List any physical/medical limitations we should be aware of, including pregnancy
Insurance Company
Insurance Policy Number
Address 1
Address 2
City
State
Zip Code
Background Screening
Have you ever been convicted of a misdemeanor?
Yes No
Have you ever been convicted of a felony?
Yes No
Have you spent any time in a prison/correctional institution?
Yes No
If you answered yes to any of the questions, please explain
Do you have a court caseworker/probation officer?
Yes No
Caseworker/Probation Officer Name
Agreement & Release

If I am chosen to be a Camp Courage LIT, I agree to comply with all rules associated with the Arizona Children's Burn Camp (Camp Courage) and the Arizona Burn Foundation. I will make every effort to attend the orientation/training session. I agree to advise the Camp Director, Coordinator(s) or designees as soon as possible if I am unable to attend Camp in order to enable others on a wait list to attend.

I hereby certify that all information provided within this application is true, and I agree and understand that any false statements or misrepresentations may cause rejection of this application or my dismissal as an LIT.

* SignatureUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
Browser doesn't support this
Clear
* Date
Transportation
Transportation to Camp
Phoenix Bus
Angel Flight
Parent will drive
Other (be specific)
Other
Transportation home from camp
Phoenix Bus
Angel Flight
Parent will pick up
Other (be specifc)
Other
Prescott Outdoors Release and Acknowledgement of Risk


Click here to read Prescott Outdoors Release and Acknowledgement of Risk full text.
* Signature of CamperUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
Browser doesn't support this
Clear
* Date
Parent/Guardian's legal responsibility for:
Parent/Guardian Name
Date
Signature of parent or gurdianUse your cursor to write your signature; if you are on a phone or tablet, use your finger to complete your signature.
Browser doesn't support this
Clear