OVERNIGHT CAMP REGISTRATION PACKET

Transcription

1 OVERNIGHT CAMP REGISTRATION PACKET

2 WELCOME TO PARADISE FARM CAMPS! PARADISE FARM CAMPS IS THE PLACE TO BE IN CHESTER COUNTY EACH SUMMER. SINCE 1875, WE HAVE BEEN PROVIDING HIGH QUALITY YOUTH DEVELOPMENT PROGRAMS IN SOUTHEASTERN PA. OUR PLACE, PROGRAMS & PEOPLE Located in East Bradford Township, Paradise Farm Camps is situated on 600 acres of scenic natural resources for our campers to enjoy and explore year after year. Our unique surroundings allow us to encourage children to open their eyes to the wonders of the outdoors and the possibilities of their own potential. Our camp is a safe place where children have the freedom to run, laugh, play, learn - and, in other words - to just be kids. Every summer, we open our special place for Overnight Camp, built specifically for children ages This special session is one amazing week of fun outdoor activities - supported by a caring community of friends, peers and staff. Overnight Campers are placed in a cabin with 6 other children of the same age and gender, along with one counselor. As a community group within the broader camp, they will live, eat, and share experiences together in an encouraging and supportive environment. Our experienced team of leaders, staff and counselors, have developed a schedule of activities intentionally designed to help each camper learn and grow - by connecting them to the outdoors and recognizing the possibilities of their own potential. The Overnight Camp counselors are trained, not only to facilitate these activities, but to help the group work together and reflect on their experiences. As youth development professionals, all team members understand their roles as models and mentors, and their number one priority is the health, safety and well-being of your children.

3 2019 OVERNIGHT CAMP AUGUST 11-17, 2019 Come join us this summer for Overnight Camp! Are you ready to make new friends, learn about the outdoors, canoe, fish, swim, and rock climb this summer? Then we are too! During this seven-day Overnight Camp, campers will connect with nature and learn valuable skills by navigating the forest; wading through waterways looking for and learning about different stream life; rolling over logs searching for decomposers; and building rafts using only natural materials found in wetlands - among many other activities. Overnight Camp evenings will be filled with fun and engaging camp wide activities like campfires, talent shows, games and pool parties. Midweek, once everyone has had a chance to settle in, the entire camp packs up and heads off-site for an exciting day trip. We will enjoy a fun and action-packed day, stop at a picnic park on the way home for pizza and games, and then return to camp for the usual nighttime activities. In the past, campers have boasted the off-site trip as their favorite experience of the week! The entire camp community shares all meals together - family style - in the camp dining hall. Family style dining helps to reinforce the concepts of teamwork and community that are continually taught at camp. All meals are prepared on-site, and nutritionally balanced, and always include a salad bar with fresh seasonal fruits and vegetables. To serve children with the most common food allergies, nothing at camp is prepared with peanuts, tree nuts, or any nut oils. Aditionally, we have experience working with a wide variety of food allergies and special diets. FINANCIAL SPONSORSHIPS EVERYONE IS WELCOME AT CAMP At Paradise Farm Camps we believe that the joy felt and relationships forged at camp should be accessible to all. Therefore, our team strives to offer children who might otherwise miss out on this amazing experience the chance to enjoy the outdoors, learn from their peers, and free their minds from every day stress. To meet this end, we have reserved 33 spots at Overnight Camp for campers whose families require financial assistance to help make their summer camp dream a reality. The total cost for a week at camp, including accommodations, meals, and all of the activities is $550 per camper. However, any camper family that qualifies for financial assistance is matched to a sliding scale which considers both income and family size. Based on this scale, families may qualify for a full or partial sponsorship. The full sponsorship covers the entire camp tuition except for the $55 registration fee, and partial sponsorships range from a $100 to $400 discount per camper. We hope you will join us for the 2019 Overnight Camp at Paradise Farm Camps - where everyone is welcome and memories last a lifetime. For more information on sponsorship and assistance see the Financial Aid form on page VALLEY CREEK ROAD DOWNINGTOWN, PA PAGE 3

4 CAMPER REGISTRATION FORM A $55 DEPOSIT IS DUE UPON RECEIPT OF THIS REGISTRATION FORM OVERNIGHT CAMP AUGUST 11 17, 2019 STEP #1: CAMPER AND FAMILY INFORMATION CAMPER S NAME: NAME OF SCHOOL: HOME ADDRESS: HOME PHONE #: D.O.B: GENDER: T SHIRT SIZE: CURRENT GRADE: CITY, COUNTY, STATE, ZIP: ADDRESS: HOW DID YOU FIND OUT ABOUT PARADISE FARM CAMPS? PARENT #1 NAME: EMPLOYER: PARENT #2 NAME: EMPLOYER: WORK #: CELL #: WORK #: CELL #: CHILD RESIDES WITH: BOTH PARENTS PARENT #1 PARENT #2 OTHER IF OTHER IS CHECKED, PLEASE EXPLAIN BELOW GUARDIAN S NAME: HOME ADDRESS: EMPLOYER: PHONE #: CELL #: CITY, COUNTY, STATE, ZIP: WORK #: ADDITIONAL CAMPERS CAMPER S NAME: NAME OF SCHOOL: CAMPER S NAME: NAME OF SCHOOL: D.O.B: D.O.B: GENDER: CURRENT GRADE: GENDER: CURRENT GRADE: T SHIRT SIZE: T SHIRT SIZE: STEP #2: EMERGENCY CONTACTS EMERGENCY CONTACT #1: RELATIONSHIP: HOME PHONE #: WORK OR CELL #: AUTHORIZED FOR PICK UP? YES NO EMERGENCY CONTACT #2: RELATIONSHIP: HOME PHONE #: WORK OR CELL #: AUTHORIZED FOR PICK UP? YES NO STEP #3: TERMS AND CONDITIONS Upon receipt of this Registration Form, a $55 non-refundable deposit is due; remainder of camp fees and current Health History Form are due by July 19th. If we do not receive full payment of camp fees by July 19th, your child will not be permitted to attend camp. Cancellations made after July 19th will be charged 50% of the total camp fee. No refunds are made to campers dismissed for inappropriate behavior, determined at the sole discretion of the Camp Director. Paradise Farm Camps retains the right to dismiss any camper if it is deemed to be in the best interest of the camp and/or the camper. Make up days are not provided. No camper may attend until a completed and current Health History Form has been submitted to and approved by the Camp Office. I hereby give permission for my child(ren) to be photographed or videotaped by Paradise Farm Camps and for the resulting images portraying my child individually or as a group participating in camp activities, to be used on various camp brochures, posters, reports, websites or as a part of a slide or video presentation to promote participation and interest in camp. I also give permission for my child(ren) to be transported in a camp vehicle or by bus to an on/offsite location for any camp field trips. I have read all of the information in this brochure and agree to all terms and conditions contained therein. PRINT NAME: DATE: STEP #4: PAYMENT INFORMATION IF PAYING BY CHECK PLEASE MAKE CHECK PAYABLE TO: CCWA IF PAYING BY CREDIT CARD CREDIT CARD NUMBER: VISA MASTER CARD DISCOVER AMERICAN EXPRESS $55 NON-REFUNDABLE DEPOSIT DUE FOR EACH CAMPER WITH REGISTRATION FORM SECURITY CODE: AMOUNT TO APPLY: EXP DATE: PLEASE MAIL REGISTRATION FORM, CAMPER HEALTH HISTORY FORM, AND DEPOSIT PAYMENT TO: PARADISE FARM CAMPS 1300 VALLEY CREEK RD. DOWNINGTOWN, PA OR SEND VIA LEAH@ PARADISEFARMCAMPS.ORG 1300 VALLEY CREEK ROAD DOWNINGTOWN, PA PAGE 4

5 CAMPER HEALTH HISTORY FORM PLEASE ATTACH A PHOTO OF CAMPER TO THIS FORM CURRENT HEALTH HISTORY FORMS ARE DUE BY JULY 19TH. FORMS SUBMITTED AFTER JULY 19TH WILL INCUR A $25 LATE FEE. SECTION #1: CAMPER INFORMATION ALL PARTICIPANTS MUST BE COVERED BY HEALTH INSURANCE CAMPER S NAME: D.O.B: GENDER: HOME ADDRESS: HOME PHONE #: CITY, COUNTY, STATE, ZIP: PHYSICIAN S NAME: PHYSICIAN S PHONE #: PREFERRED HEALTH CARE FACILITY: HEALTH INSURANCE CARRIER: POLICY #: GROUP #: A COPY OF THE FRONT AND BACK OF THE INSURANCE CARD MUST BE ATTACHED TO THIS FORM SECTION #2: MEDICAL HISTORY INFORMATION ATTACH A SEPARATE SHEET IF NECESSARY DESCRIPTION OF ANY PAST MEDICAL TREATMENT (INCLUDE DATES OF TREATMENT) PLEASE DESCRIBE ANY CURRENT PHYSICAL, MENTAL OR PSYCHOLOGICAL CONDITIONS REQUIRING MEDICATION, TREATMENT, OR SPECIAL RESTRICTIONS OR CONSIDERATIONS WHILE AT CAMP: HAS YOUR CHILD EVER BEEN ON A MEDICATION FOR BEHAVIOR OR EMOTIONAL PROBLEMS? PLEASE EXPLAIN: HAS YOUR CHILD EVER BEEN HOSPITALIZED FOR A MENTAL OR EMOTIONAL PROBLEM? IF SO, PLEASE EXPLAIN WHEN, FOR HOW LONG, AND WHAT WAS THE DIAGNOSIS? DESCRIPTION OF ANY CAMP ACTIVITIES FROM WHICH THE CAMPER SHOULD BE EXEMPTED FOR HEALTH REASONS: ALLERGIES (INCLUDE FOOD, DRUGS, BEE STINGS, ETC): DIETARY RESTRICTIONS (VEGETARIAN, RELIGIOUS, ETC): MEDICATIONS: PLEASE LIST ALL CURRENT MEDICATIONS INCLUDING PRESCRIBED AND OVER-THE-COUNTER DRUGS TAKEN. ATTACH A SEPARATE SHEET IF NECESSARY. MEDICINE #1: MEDICINE #2: MEDICINE #3: MEDICINE #4: WE DO NOT REQUIRE THAT YOU SUBMIT A COPY OF YOUR CHILD S IMMUNIZATION RECORD, BUT DO REQUIRE THAT YOU ANSWER THE QUESTION BELOW: DO YOU ATTEST THAT ALL IMMUNIZATIONS REQUIRED FOR SCHOOL ARE UP TO DATE FOR YOUR CHILD? YES NO WE DO REQUIRE THE LAST DATE (MONTH/YEAR) OF YOUR CHILD S LAST TETANUS SHOT. DATE OF LAST SHOT: PAGE 5

6 CAMPER HEALTH HISTORY FORM PLEASE ATTACH A PHOTO OF CAMPER TO THIS FORM CURRENT HEALTH HISTORY FORMS ARE DUE BY JULY 19TH. FORMS SUBMITTED AFTER JULY 19TH WILL INCUR A $25 LATE FEE. SECTION #3: PARENT/GUARDIAN PERMISSION TO TREAT AGREEMENT This Medical Release states the risks of illness, injury, harm, and medical procedures at CCWA-PARADISE FARM CAMPS. It has important legal consequences. You should decide to send your child to camp only after you have read and understood the Medical Release Statement and decided that you wish you and your child to be bound by its terms. For your convenience, you (or each of you) is referred to in the Agreement as I and your child is referred to as my camper and the Children s Country Week Association and all of its officers, directors, employees and agents are referred to together as the Association. I am the parent or legal guardian of (Camper s Name). I understand that camping has many risks. It involves such things as vigorous physical activity, the close gathering of large groups of people, communal living arrangements, and a rural outdoor setting. Participation in camp activities may entail exposure to serious risks posed by the natural and/or outdoor environment, such as tick borne diseases including Lyme Disease and Rocky Mountain Spotted Fever, Poison Ivy, etc. If my camper becomes ill or is injured while at camp; I understand that my camper will first be evaluated by the Camp Health Service Provider or a Physician selected by the Association, and I authorize him or her to make all inquires, examinations and tests he or she deems necessary or appropriate. If he or she determines that it is appropriate to administer treatment at the Camp, I authorize that treatment. I release the Association from all liability which may result from the evaluation and treatment of my camper by the Camp Health Service Provider or that Physician. If the Camp Health Service Provider or that Physician determines that other treatment is necessary or appropriate, I want the Association to try to reach me or those emergency contacts designated in the registration form in the order listed. If reached, I will tell you whether and by whom I wish my camper to be treated. In an emergency, or if I cannot be reached in a timely fashion, I authorize the Association to deliver my camper to a Health Care Provider selected by the Association, for such treatment as that Provider considers appropriate. I agree that the Association shall not be responsible for what happens after my camper has been returned to me or delivered to a Health Care Provider so chosen by me or the Association, and I release it from all liability therefore. I agree that I am responsible for the cost of any outside health care provided and the cost of transporting my camper. The undersigned agrees to be bound by and to have the undersigned s camper be bound by this agreement. PRINT NAME: DATE: SECTION #4: HEALTH EXAM ATTACH ADDITIONAL INFORMATION IF NEEDED THIS SECTION IS ONLY REQUIRED FOR CHILDREN ATTENDING ANY SLEEPAWAY SESSION, AND MUST BE SIGNED BY A LICENSED PHYSICIAN ACA ACCREDITATION STANDARDS SPECIFY PHYSICAL EXAM WITHIN THE LAST 12 MONTHS. MEDICAL PERSONNEL: PLEASE REVIEW THE FRONT OF THE CAMPER HEALTH HISTORY FORM AND COMPLETE THE REMAINING SECTIONS OF THIS FORM. PHYSICIAN S NAME: DATE OF EXAMINATION: HEIGHT: WEIGHT: BP: BLOOD TYPE: DO YOU FEEL THAT THE CAMPER WILL REQUIRE LIMITATIONS OR RESTRICTIONS TO ACTIVITY WHILE AT CAMP?YES NO IF YES, WHAT ARE YOUR RECOMMENDATIONS: PAST OR CURRENT HISTORY: PLEASE CHECK ALL THAT APPLY ASTHMA SKIN PROBLEMS MEASLES DIABETES GASTROINTESTINAL PROBLEMS CHICKEN POX CHRONIC, RECENT OR RECURRING ILLNESS SEIZURES GERMAN MEASLES CARDIOVASCULAR DISORDERS EMOTIONAL/BEHAVIORAL MUMPS NEUROLOGICAL DISORDERS DEVELOPMENTAL PROBLEMS HEPATITIS A BED WETTING OTHER MEDICAL CONCERNS HEPATITIS B OTHER CONCERNS: HEPATITIS C I HAVE REVIEWED THE CAMPER HEALTH HISTORY FORM, AND HAVE DISCUSSED THE CAMP PROGRAM WITH THE CAMPER S PARENT(S)/GUARDIAN(S). IT IS MY OPINION THAT THE CAMPER IS PHYSICALLY AND EMOTIONALLY FIT TO PARTICIPATE IN AN ACTIVE CAMP PROGRAM (EXCEPT AS NOTED ABOVE.) OFFICE ADDRESS: DATE: PHONE #: ALL CAMPERS MUST HAVE A CURRENT CAMPER HEALTH HISTORY FORM RETURNED TO THE CAMP OFFICE BY JULY 19TH. ANY CAMPER WITHOUT A CURRENT CAMPER HISTORY FORM BY JULY 19TH WILL BE SUBJECT TO A $25 LATE FEE AND MAY HAVE THEIR REGISTRATION REMOVED ANY VALLEY QUESTIONS CREEK OR ROAD CONCERNS, DOWNINGTOWN, PLEASE CONTACT PA CAMP DIRECTOR, JESSIE LEONE AT PAGE 6

7 PARADISE FARM CAMPS 1300 VALLEY CREEK ROAD, DOWNINGTOWN, PA PHONE FINANCIAL AID FORM Limited Financial Aid is available to attend our Summer Camp Programs. Children s Country Week Association (CCWA) reserves the right to make all decisions regarding applications submitted for Financial Aid. Financial Aid may be awarded to families earning less than $85, a year. Financial Aid is awarded in full or partial session sponsorships. If a family is awarded a partial sponsorship, families and/or guardians will be responsible for paying fees according to the arrangements created by the Organization. After we receive your information, we will contact you to inform you of our decision. Please follow the steps below to complete this form. STEP #1: PERSONAL LETTER Each application must include a short letter briefly explaining your personal situation and the circumstances. Your letter should also include: The names and ages of your child(ren) wishing to attend camp An explanation of your financial situation, including amount you can contribute Why you believe attending Paradise Farm Camps will benefit your child(ren) STEP #2: CALCULATING TOTAL FAMILY INCOME Record the number of Household Occupants in the green box below. Household Occupants consist of the number of immediate family members residing in your home. Determine your Total Family Yearly Income using the following formula: [(GROSS MONTHLY WAGES) + (WELFARE/CHILD SUPPORT/ALIMONY, ETC.) + (PENSIONS/SOCIAL SECURITY) + (ALL OTHER INCOME)] X 12 = TOTAL FAMILY YEARLY INCOME HOUSEHOLD OCCUPANTS GROSS MONTHLY WAGES WELFARE / ALIMONY CHILD SUPPORT, ETC. PENSIONS / SOCIAL SECURITY ALL OTHER INCOME TOTAL MONTHLY INCOME = TOTAL YEARLY INCOME = $ $ x 12 STEP #3: VERIFICATION OF INCOME You must attach copies of the following documents to verify Total Yearly Income: Most Recent Pay Stubs of both Parents and/or Guardians Current IRS 1040 Income Tax Return STEP #4: AND AUTHORIZATION I hereby affirm that the above information is true and correct to the best of my knowledge. In the event that CCWA awards Financial Aid to my child, I agree to pay any and all Camp fees and provide a completed Camper Health History Form. DATE: PRINT NAME: RELATIONSHIP TO CAMPER: Each application is processed with a case-by-case evaluation. Sponsorship opportunities are limited, and will be awarded to families based on both level of need and availability. If you have any questions in regards to this form or about the process in general, please contact Leah at x VALLEY CREEK ROAD DOWNINGTOWN, PA PAGE 7