Camp Go Beyond: Physician's Evaluation Form

Welcome to Camp Go Beyond Physician's Evaluation Form.

Welcome! Thank you for agreeing to fill out this short form - it will help us decide whether to admit the applicant to our camp this year. This form is to be completed by the camper's Pediatric GI physician or PNP.

Submitting for Multiple Patients?

If you are submitting forms for multiple patients,

1. Fill the form and SUBMIT for the first patient.
2. Copy or bookmark the URL / link to this form.
3. Close the browser, reopen it and go back to that link.
4. You will most likely get a blank form.
5. Re-enter the data.

About Camp Go Beyond

Camp Go Beyond is a free annual camp for children with IBD. For more information about the camp, please visit us at
www.campgobeyond.org . Thank you!

Questions?

Please contact:

Janele Auranicky
jauranicky@gmail.com

Primary Fax: 415-353-2474 (ATTN: Laura)

Secondary Fax: 415-895-5485

Printable form can be found here: https://goo.gl/mMQkVT

Thank you for your time and support.

- Camp Go Beyond

www.campgobeyond.org

Camper's Medical Information:

Camper's Last Name:
*

Camper's First Name:
*

Diagnosis:
*

0/1000 characters

Extent of disease:
*

0/2000 characters

Patient's Medical History we should know about:

0/2000 characters

Extraintestinal Manifestations:

0/2000 characters

Medications:
*

0/2000 characters

Immunizations *

The above-named Camper is physically able to participate in Camp Go Beyond located at Camp Arroyo in Livermore, CA, a camp for kids with Inflammatory Bowel Disease (IBD), sponsored by The Taylor Family Foundation and the IBD Summer Camp Foundation. I understand that a Pediatric Gastroenterologist and PNPs will staff the camp health center during the duration of camp.

Should Camp Go Beyond Accept or Decline this candidate?
*

Accept

Decline

Please explain:
*

Your Contact and Identification Information:

Physician's Last Name:
*

Physician's First Name:
*

Street Address:
*

City:
*

State:
*

Zip Code:
*

Phone Number: (111-222-3333)
*

Email Address:

Retype Email Address:

Please enter your professional identification information for verification purposes only. We promptly destroy this information after our decision on camper's application. Thank you.

Please indicate which identification you would prefer to provide:
*

State Medical License #

DEA #

State License #:
*

State:
*

DEA #:
*

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