KIDDO CAMP PACKING LIST

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4 KIDDO CAMP PACKING LIST WHAT TO PACK IN 22 GALLON (or smaller) Plastic tub with lid -- LABEL with your child's first and last name please!! WHAT TO BRING Sleeping bag, or twin sheets and cover Pillow and pillow case ShortsT-shirts Tennis shoeswater shoes SEVERAL PAIRS OF SOCKS REQUIRED Swim suit (girls - one-piece only)swim trunks (multiple pairs recommended for guys -- LABEL!!) Light jacket and raincoat Brush or comb Toothbrush and toothpaste Soap and shampoo Towels and wash cloths Flashlight and batteries Two 30- gallon trash bags Sunscreen Insect repellent Creek walkin shoes - Bring an old pair of shoes that you can secure to wear to go creeking. They will be wet! 5th graders - 1 pair of long pants for special activity LABEL ALL ITEMS WITH FIRST AND LAST NAME! Medications needed-- all meds both prescription and over the counter must be checked in to nurse and medicine form completed by parent. Inhalers and epipens will be with the child's counselor at all times.

5 WHAT NOT TO BRING v No electronics allowed! Campers are not allowed to use cell phones, etc. v No food or snacks can be brought or kept in cabins. If food allergies or special food needs exist, please see camp staff to make needed arrangements. v No shaving cream water balloons,etc. etc. etc. allowed v Clothing should be modest and in good taste. Shirts should cover tummies and backs. v No flip flops except in the shower v NO BIBLES NEEDED due to Bibles being lost andor damaged at camp. We will have scripture printed in camper books.

6 ParentGuardian: please complete all Five Sections. If not applicable, please write none in section. All campers with parentguardian must register at Nurses Station even if they do not take any prescription medications. I hereby authorize Valley View Church personnel to administer medication to my child,, as listed below. I release the personnel from responsibility for any adverse reactions to this medication. ParentGuardian Signature: Date: Phone (best contact): 2nd Phone Number: Please list any allergies to drugs, food or other. Describe symptoms of a reaction and treatment course. Epipen Sent: yes no Given To: Nurse Counselor (I.e. recent illnesses, injuries, surgeries, breathing difficulties) Routine medication is only administered at breakfast (B), lunch (L), supper (S) and bedtime (Bd). Please indicate your choice of time. Has this morning s medicine been given? Yes MEDICATIONSTRENGTH DOSAGEDIRECTIONS B L S Bd REASON PRESCRIBED No Ex. Concerta 18 mg 1 tablet daily x ADHD Inhaler Given to: Nurse Counselor *Parents: Complete Top of Back Page

7 Your permission is REQUIRED to give ANY meds to your child. Checkmark and your initials indicate your permission to administer the following: My child,, may take the following medications as needed based on package directions- Tylenol (acetaminophen) Advil (ibuprofen) SinusAllergy Meds Tums Topical Ointments (Neosporin, etc.) Other Other Other Other Parent s Initials: ***********Below: For camp nurse use only.*********** Camper brought own over-the-counter medications: yes no Name of MedicationStrength Dosage Reason Date TimeInitials Nurse Check-In By: Nurse Med Labels By: Nurse Verified By: Team Color: Counselor: Revised

8 Authorization for Consent to Medical Treatment of Minor Child Iwe hereby authorize the adult workers of Valley View Church to give consent for all medical andor surgical treatment that may be required for our child while in Valley View Church care. I also release Valley View Church and its employees, agents, and volunteers from any liability in the event of an accident. Child s Full Name Date of birth Child s Physician: Child s Allergies Medications child is taking: Important medical history Date of last Tetanus Immunization Home address of parentguardian: Parentguardian Telephone # : Cell # Emergency contact (other than parentguardian): Telephone: Cell: Primary Medical Insurance Carrier Member s Name ID# Group # Signature of parentguardian(s) Date signed Signature of adult witness

9 YMCA of Greater Louisville 545 South Second Street Louisville, KY (P) YMCA CAMP PIOMINGO GENERAL RELEASE OF LIABILITY FOR HIGH RISK ACTIVITIES 2018 PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS! PARTICIPATION AGREEMENTASSUMPTION OF RISK & RELEASE: Please READ & SIGN this Statement. Incomplete forms will be returned. Whereas, the undersigned (the Applicant ) wishes to be accepted for participation in all camp activities including High Risk activities if scheduled,conducted by YMCA of Greater Louisville Camp Piomingo, and in consideration of YMCA of Greater Louisville Camp Piomingo action in allowing the Applicant to participate in such program. The undersigned acknowledges that during the said activities that the Applicant isrequested to participate in, that certain risks and dangers may occur. These include but are not limited to the hazards of depending on other people and being at various heights (ground to 50 ), accident or illness in remote places without medical facilities, the forces of nature and travel by air, train, boat, automobile or other conveyance. The undersigned further recognizes risks may also include loss or damage to personal property, physical or psychological damage andor injury not excluding fatality due to accidents which may occur, including accidents resulting from this challenge course experience or other type of outdoor activities. I further understand that in participating in the activities I am requesting to participate in, I could be exposed to the elements of nature, including temperature extremes, and inclement weather. I further understand that medical treatment may be several minutes to hours away in the event of a medical emergency. In consideration of and a part of payment for the right to participate in such a program and the services and food arranged for me by YMCA of Greater Louisville Camp Piomingo, its board of Management, Officers, Employees, Agents, andor Associates I have and do hereby assume all the above risks and any other ordinary risk incidental to the nature of the program, including risks which are not specifically foreseeable, and will hold them harmless from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss or otherwise, which I now have or which may arise from or in connection with my program or participation in any other activities arranged for me by YMCA of Greater Louisville Camp Piomingo, its board of Management, Officers, Employees, Agents, andor Associates, and their heirs, executors and administrators. The terms hereof and my signature on this document shall bind my heirs, representatives, executors, and administrators, successors, and assigns and for all members of my family, including any minors accompanying me. I also state that I am not

10 under, and will not be under the influence of any chemical substance including alcohol. I fully understand that any physical activity involves risk of injury. I also understand that my participation in the YMCA of Greater Louisville Camp Piomingo program is entirely voluntary and that I may excuse myself from participation if I so desire. I hereby enroll in YMCA Camp Piomingo Programming. In signing this application, I certify that heshe is healthy and free of problems that could adversely affect hisher stay or that of other campers at YMCA Camp Piomingo. I agree to pay the balance of camp fees on or before that fee is due. I understand that reserved spaces cannot be held without full payment. I grant permission for the applicant to participate in all planned camp activities. My child has permission to leave the YMCA Camp Piomingo grounds with authorized Camp Staff in authorized Camp vehicles for scheduled trips and outings. I fully understand the inherent risks involved in activities my child will be choosing or has already chosen. I, the parentguardian, accept all risks including those activities preliminary and subsequent to the chosen activities. I hereby grant the YMCA Camp Piomingo and its agents full authority to take whatever actions they deem necessary regarding my child s health and safety, and I fully release YMCA Camp Piomingo from any liability in connection there within. I understand that prudent attempts will be made to contact the undersigned immediately. I understand that there is no accident or medical insurance provided and that I will be responsible for payment of all medical and medication bills. Parents will be expected to pre-pay any medical office co-pays and for any prescriptions picked up for their child while at camp. I understand that my child must comply with the camp s rules and standards of conduct and that the organization may terminate my child s participation in the camp program if heshe does not maintain these standards. I authorize YMCA Camp Piomingo, without limitation or obligation, to use photographs, film footage or tape recordings which may include my child s image or voice for purposes of promoting or interpreting YMCA Camp Piomingo programs and release the camp from any claim or liability to that use. While YMCA Camp Piomingo will make every attempt to provide reasonable accommodations for mentally and physically challenged children, the camp will not accept children that are (1) of danger to themselves, (2) of danger to others, or (3) a disruption to the normal activities making it unreasonably difficult for other children to enjoy camp programs. Any of the above reasons will be grounds for dismissal from camp. A parentguardian must discuss with the director any special conditions or circumstances involving their child. This must be done prior to registration so that we can advise you as to whether we can make a reasonable accommodation for your child. YMCA Camp Piomingo is not responsible for lost, stolen or damaged personal articles. Name of Participant (Please Print) Signature of Parent or Guardian Date Signature of Witness Date