2018 CAMP PUGWASH BLIND CAMP APPLICATION INSTRUCTIONS

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1 Maritime Conference of the Seventh-day Adventist Church Inc. Camp Pugwash Gulf Shore Road Pugwash NS B0K 1L CAMP PUGWASH BLIND CAMP APPLICATION INSTRUCTIONS MAIL $50 NON-REFUNDABLE APPLICATION FEE (money orders or cheques made payable to Maritime Conference of SDA) and COMPLETED APPLICATION FORM TO: Camp Pugwash - Blind Camp 121 Salisbury Rd, Moncton NB E1E 1A6 CAMP DATES: JUNE 24 JUNE 29, 2018 APPLICATION FORM AND FEE SHOULD BE RECEIVED BY JUNE 4, Please use ink and print clearly. 1. ALL INFORMATION is essential. Please fill in every blank. 2. MEDICAL INFORMATION MUST BE COMPLETED. o First Time Camper - must visit your physician and have the form filled out and signed. o Returning Camper with ongoing or recent medical care - must visit your physician and have the form filled out and signed. o Returning Camper without ongoing or recent medical care - no visit is necessary but please neatly PRINT PHYSICIAN S INFORMATION. o Ophthalmologist s Name & Number MUST be filled in, if applicable. o When applicable, additional Medical Insurance Name and Policy Numbers must be filled in, especially for prescriptions. o Any additional instructions for the camp first aid attendant must be received in writing and all prescriptions updated. o All medications MUST be in original containers. o All campers with bee/insect sting allergies, must come to camp with a filled prescription for antidote medication. 3. Notification information for children 18 years or younger must be a parent or legal guardian. 4. CONSENT AND RELEASE section must be signed by a parent, legal

2 guardian or the adult camper (18 years or older). Some activities may require additional signed waivers.

3 CAMP PUGWASH BLIND CAMP APPLICATION JUNE 24 - JUNE 29, 2018 APPLICATION TO BE COMPLETED AND RETURNED FOR EACH CAMPER, INCLUDING PERSONAL SERVICE WORKERS. INCOMPLETE APPLICATIONS WILL BE RETURNED. Office Use Only Date Rec d Fee Rec d Legally blind and visually impaired: Central visual acuity for distance is no greater than 20/200 in the better eye with correction. Attended camp before at Camp Pugwash Yes No Camper s name Last First Initial Mailing Address City Province Postal Code Phone ( ) Male Female Height Weight Age Birth date (M/D/Y) T-shirt size Adult S M L XL XXL XXXL XXXXL Child 6/8 10/12 14/16

4 -2- Extent of Blindness Details Totally Legally Sighted Guide Guide dog Cane travel Glasses Contact lens(es) No Yes right left Artificial eye(s) No Yes right left Care of contact lens(es)/artificial eye(s) Camper cared for independently No Yes First aid attendant to take care of No Yes If first aid attendant cared for, please give details of removal, care, reinsertions, solutions, & frequency, etc: CNIB # Provincial Health Care # (must be filled in) Medical Insurance Name Policy/Group/ID/Rx Number s In case of accident or illness, notify: Name Relationship to camper Home Phone # ( ) Work # ( ) Cell # ( )

5 Address Vac. Address Vac. Phone # ( )

6 -3- HEALTH HISTORY Infections/disease(s) No Yes If yes, please explain. Asthma No Yes Thyroid disease No Yes Eating Disorder No Yes Diabetes No Yes insulin pill diet Epilepsy No Yes grand mal petite mal Date of last seizure Ear infections No Yes Previous surgeries No Yes Sinusitis No Yes Kidney disease No Yes Heart disease/murmur No Yes Frequent cold/sore throat No Yes Other: MEDICATIONS taken at home (include name, dose and time taken - print)

7 MEDICATIONS: Camper cared for and administered No Yes First aid attendant cared for and administered No Yes INITIALS: (PARENT/GUARDIAN)

8 -4- ALLERGIES/ALLERGIC REACTIONS a) Bee/Insect stings No Yes Reaction Severe Moderate Mild Antidote Benadryl Anakit Epikit Other: Camper cared for and administered No Yes First aid attendant cared for and administered No Yes b) Penicillin No Yes c) Other Medication No Yes d) Food No Yes e) Environmental No Yes f) Anaesthetic No Yes g) Other DATE of last tetanus/polio immunization booster DIETARY RESTRICTIONS - Please list: LIMITATIONS/RESTRICTIONS OF ACTIVITIES AT CAMP No restrictions Archery Belly boarding Canoeing Crafts Horse shoes Horseback riding

9 Sailing Swimming Water skiing Other:

10 -5- FAMILY PHYSICIAN/PAEDIATRICIAN (must be filled in): Name Office # ( ) Address I have examined the person herein described and have reviewed his/her health history. It is my opinion that he/she is physically able to engage in camp activities except as noted on page 4. Physician s Signature Date OPHTHALMOLOGIST (must be filled in): Name Office # ( ) Address GUIDE DOGS: It is the camper s responsibility to feed, exercise and clean up after their dog. IMPORTANT: Our camp is smoke-free. There is a zero-tolerance policy for alcohol and illegal drug use. Firearms, weapons or explosives are not allowed at camp. Sexual promiscuity is not allowed at camp.

11 Maritime Conference of the Seventh-day Adventist Church Inc. Camp Pugwash Gulf Shore Road Pugwash NS B0K 1L CAMP PUGWASH BLIND CAMP CONSENT, RELEASE AND AUTHORIZATION -6- I hereby give my consent for (name of applicant) to attend camp from June 24 - June 29, In case of accident, illness, or death, I will not sue the camp, or its management. This health history is correct as far as I know, and applicant has permission to engage in all camp activities, except as noted. In the event I cannot be reached in an emergency, I give permission to the physician, selected by the camp first aid attendant/adult leader in charge, to authorize any treatment necessary. (Guardian/parent initials) Camp Pugwash will be notified 3 weeks prior to camp if the applicant has been exposed to a communicable disease. I understand that campers may be photographed for use by news media, publications or promotion. I consent for Camp Pugwash to use, in any manner, all photographs and recordings made. This applicant is legally blind. Signature Date Relationship to applicant **************************************************************************** Office Use Only Approved Yes No

12 Reason