CAMP MEDICAL | Sickle Cell

First Name

Last Name

Birthday

Phone

Street Address

City

Zip code

State

Which of the following would you like to assit with?

Sun Check-In (Atlanta)

Fri Arrival (Atlanta)

Campsite (Fortson 4-H Center)

Too Early to Tell

Prefessional License #

Briefly describe your camp experience. Include type of camp and your role (e.g. camper, volunteer staff).

What skills, experience, and/or certifications do you possess that will contribute to the quality of the medical team?

What Hospital, Clinic or Medical Facility are you affiliated with?

I hereby certify that the above information is correct. I authorize that the Sickle Cell Foundation of Georgia, Inc. to perform a criminal history and sexual offender check, for the purpose of certifying that i have not been convicted of a crime.

Your Signature