The Salvatio n Army Kim Schwich PO Box 182 Green Isle, MN

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1 2018 Camper Application The Salvatio n Army Kim Schwich PO Box 182 Green Isle, MN Kim_Schwich@usc.salvationarmy.org CAMP SESSIONS ATTENDING OFFICE USE ONLY Date Received: Complete YD Initial: Name: Corps: Last First Kids Camp: June 18th-21st Completed Grades 1st-6th Teen Camp: July 2nd-6th Completed Grades 7th-Age 17 Note: A Salvation Army Service Unit Representative must review this for completeness and sign it before the camper will be registered. (See page 3) CAMPER INFORMATION Camper Name (Last) (First) Address: Age: Date of Birth: / / Gender: Grade Completed Spring 2017 City: State: Zip Code: Phone: ( ) Corps/Church Affiliation (or None ): PARENT/GUARDIAN/SPOUSE INFORMATION Parent/Guardian/Spouse Name: Address (If different from above): Address: Phone Number: ( ) Relationship to Camper: Parent/Guardian/Spouse Work or Emergency Phone Number: ( ) Additional Parent/Guardian/Spouse Emergency Phone Number: ( ) IF PARENT/GUARDIAN/Spouse NOT AVAILABLE, CONTACT(Must be someone who is available throughout the encampment): Name: Relationship to camper: Complete Address: Home phone number: ( ) Cell phone number: ( ) CODE OF CONDUCT I Agree to abide by the following code of conduct and rules instituted for the benefit and safe participation of all campers and staff: 1. To dress appropriately for recreational purposes and wear whatever clothing and/or equipment deemed necessary by the camp. Modest one-piece bathing suits must be worn while swimming. Bikini, thong, French-cut or similar low cut back or high legs styles are not permitted. 2. To respect the rights, privacy, and property of others by not stealing, fighting, lying, cheating, etc. 3. To respect the property and facilities of the camp, The Salvation Army, and adjoining properties. 4. To attend and participate in all scheduled programs, activities, and meals and to abide by the curfew established by the camp in a courteous, respectful, and prompt manner. 5. Not to possess or use any alcohol, tobacco, or non-prescription drugs during camp, not to bring flammable or explosive materials, poisons, weapons, or pets to camp.(all medications must be turned in to the Camp Nurse at registration.) 6. To respectfully cooperate with camp staff, other campers, and visitors of Northwoods Camp. 7. To abide by all local, state, and federal law. 8. To obey all rules of Northwoods Camp and to comply with all routine and emergency instructions of the camp staff. 9. To attend and be respectful of all worship services, classes, and sessions. 10. To stay on camp grounds throughout the camping session. 11. Not to enter any cabin I am not assigned to. Girls and Boys are not allowed in opposite gender cabins. 12. Absolutely NO electronic devices such as cell phones, gaming systems, Tablets, etc. In emergency situations camp phones will be used. Electronic devices will be confiscated if brought to camp, and will be given back at the end of the encampment. The rules, regulations, procedures, and the Salvation Army s Northwoods Camp philosophy have been discussed with me. I have full understanding of them and agree to abide by them. I understand if I break these rules, I may be sent home. Camper Signature: PHYSICIAN INFORMATION Name of family Physician: Phone Number:( ) Date of last physical examination: / / Family Insurance Carrier: Policy #: **A COPY OF THE CAMPER S HEALTH INSURANCE CARD & Immunization Records MUST BE ATTACHED** Page 1

2 Camper s Name: (Last, First) HEALTH HISTORY (Check giving appropriate dates of last incident) Bleeding/Clotting Disorder Heart Defect/Disease: ALLERGIES: Convulsions/Epilepsy: Hypertension: Asthma: If yes, does camper carry medication? Heat/Sun-Related Problems: Mononucleosis: Hay Fever: Penicillin: Frequent Ear Infection: Diabetes: Insect Stings: Insect Repellent: ADD/ADHD: (if yes, is camper currently taking medications?) Poison Ivy: If yes, please describe. Include dates, and list any resulting physical limitations, etc. (Please circle) Operation/Serious Injuries? No Yes Current Infectious Diseases? No Yes Dietary Modifications/Food Allergies? No Yes Other diseases or details of above: (Female) Has this person menstruated? No Yes If yes, is her menstrual history normal? No Yes Authorization for Administration of Medication at Northwoods Camp The administration of medication at Northwoods Camp shall be done only under the following guidelines. The administration of ANY medication, prescription or non-prescription, at Northwoods Camp requires: 1. The original labeled container; with camper s name, dosage, frequency, Doctor s name, & prescription number. 2. Written physician s order and physician signature for any prescription medications (Section A below). 3. Written permission by the parent for non-prescription over-the-counter medications (Section B below). The parent is responsible for providing any necessary prescription medications prior to departure. Send medication in the original labeled container to camp. To authorize the administration of medication, please complete the form below and return it with your camp application. To authorize other health procedures, please contact the Divisional Youth Secretary for specific requirements & instructions. A. PHYSICIAN/LICENSED PRESCRIBER ORDER FOR ADMINISTRATION OF PRESCRIPTION MEDICATION I hereby authorize the administration of the following medication at Northwoods Camp and release camp personnel from liability should reactions result from medication administered by them: MEDICATION INFORMATION *Please list all medications including inhalers, Epipens, and Diabetes Medications. Name of Medication Dosage Frequency & Time of Day Given *If you have more than 5 medications please request a print out from your doctor with their signature on it* Any specific activities to be encouraged or limited, behavioral considerations, or special health-related information for Camp personnel or Camp Nurse? Physician Signature Date: Phone: Fax: *Physician Signature must be dated within 90 days of camp attending, even if camper does not have medications. ** If Physician does not sign, this application will be incomplete and sent back for signature. B. PARENT PERMISSION FOR NON-PRESCRIPTION OVER THE COUNTER MEDICATIONS: The following are medications that are stocked in the Northwoods Camp Health Center. These medications are dispensed as directed by Standing Orders Signed by Northwoods Camp s Nurse and are used only when necessary to manage common illnesses or injuries in the camp setting. Children s Acetaminophen (Children s Tylenol) Acetaminophen (Tylenol) Ibuprofen (Motrin, Advil) Children s Ibuprofen (Children s Advil or Motrin) Aloe Vera Gel Bismuth subsalicylate (Pepto Bismol) Loperamide (Imodium) Antibiotic Ointment (Neosporin) Hydrocortisone Cream Diphenhydramine Hydrochloride (Antihistamine or Benadryl) Diphenhydramine Topical (Benadryl cream/gel/spray) Children s Diphenhydramine Hydrochloride (Children s Antihistamine or Benadryl) Claritin Eye Drops(Visine, Tears) Please List any of these medications which are NOT to be used on the camper: Page 2

3 ADVENTURE PROGRAM The Salvation Army Northwoods Camp Adventure Program consists of high ropes, low ropes challenge course, swimming pool, exploring, trailblazing, boating, paintball, archery and pellet gun target shooting, and ATV safety courses. The Adventure Program involves a variety of activities that often include warm-ups, games, trust experiences, low and high elements, water activities, and other rigorous physical adventure activities. Participation in the rigorous activities is an individual choice. There are risks, which must be assumed by each participant, and understand that her or she may suffer an emotional or physical injury or disability The Salvation Army Northwoods Camp requires that every participant have health/accident insurance coverage. Furthermore, certain health/medical information must be made known to the instructor(s) so that they are prepared to help participants make informed choices about their level of participation. Release of Liability and Assumption of Risk: I understand that parts of The Salvation Army Northwoods Camp Adventure Program may be physically and emotionally demanding. I affirm that the camper listed on the application is in good health, and that he or she is under a physician s care for any undisclosed condition that bears upon fitness to participate in any activities presented by the Northwoods Camp Adventure Program. I recognize the inherent risk of bodily injury, property damage, damages, losses, and/or death that may arise from my aforementioned participating in the Northwoods Camp Adventure Program activities. I understand that each participant must assume the risk of physical injury that could result from any of these activities. I release The Salvation Army Northwoods Camp and staff members, their agents, owners, officers, volunteers, partisans, and the Board of Directors, from all liability for any injury or disability that may occur while participating in The Salvation Army Northwoods Camp Adventure Program Activities. PARENT/GUARDIAN Authorizations & Policy Understandings Camper s Name: (Last, First) (Please initial/sign the following Statements) Program Activities will take place at Northwoods Camp Elbow Lake Rd. Finlayson, MN Our Staff are First Aid/CPR certified. Adventure Activities: I have read and agree to the Northwoods Camp Adventure Program. I hereby give permission for the camper listed in the application to participate in the Adventure Programs including: Swimming: To the best of my knowledge, the named participant s swimming ability can be classified as: Beginner Intermediate Expert High Ropes/Zip Line Low Ropes Pellet Gun shooting Paintball Archery ATV Photograph Release: Photo/Media Consent please indicate whether you DO or DO NOT grant The Salvation Army the right to use, reproduce, assign and/or distribute photographs, films, videotapes, and sound recordings of my child/myself for use in materials they may create for marketing including social media without compensation. This will be used in accordance to the policies of The Salvation Army. I DO CONSENT I DO NOT CONSENT Camper Release Policy: It is our intent that children attending camp do so for the entire camping period. There are, however, emergency situations when campers must leave early. In those cases, campers will be released to the representative of the sponsoring agency bringing the child to camp or a legal parent/guardian whose signature appears on the camper s registration form. Campers WILL NOT be released to any other person without written consent signed by the legal parent/guardian and prior notification of the camp office, (320) Thank you for your cooperation in this policy. It is intended for your child s safety. Head Lice Policy: I understand that campers MUST have NO EVIDENCE of Head Lice, Eggs, or Nits before coming to camp. Campers who have evidence of Head Lice, Eggs, or Nits (dead or alive) will be sent home without exception. Health History: This health history is correct to the best of my knowledge. The person herein described has permission to engage in all prescribed camp activities except as noted by me on the informed consent portion of this application. I have reviewed and consent of the Camper Release Policy and the camper Code of Conduct. Parents will be notified immediately of any injury or illness requiring off-site treatment. Medical Treatment: I give permission to The Salvation Army Northwoods Camp to secure emergency medical and surgical treatment (including, but not limited to x-rays, routine test, injections, and anesthesia) and hospitalization for this child if there is insufficient time to contact me. I further authorize routine, nonsurgical medical care (including dispensing of non-prescription drugs for illness, the treatment of injury, insect bites, etc.) at the discretion of the camp nurse. I give permission for (Camper Name) to attend The Salvation Army Northwoods Camp. I certify that all information given in this application is true to my ability. Parent/Guardian Signature: Date: Parent/Guardian Name (Printed): FOR CORPS OFFICER/SALVATION ARMY REPRESENTATIVE USE ONLY (Check off as items are accomplished) Camper will not be registered until all items are completed Copy of Health Insurance Card Copy of Immunization Records Camper Signature on Code of Conduct(Pg. 1) Northwoods Camp Physical/Medication Form with Doctors signature(pg. 2) Parent/Guardian initials & Signature (Pg. 3) Food Service Form (Please make sure EVERYTHING is filled out) (Pg. 4-6) ATV Safety Course Consent Forms if applicable (Pg. 7-9) *Note: Dr. Signature is required even if the child does not have medication Salvation Army Service Unit Representative Signature: Date: Print Name Phone Number( ) Page 3

4 SE TEEN CAMP ONLY ATV-Safety Course This class is a 4hour ATV Safety Course Taught by Certified instructors. Upon completion of the course the student will receive a ATV RiderCourse Completion Card issued by the ATV Safety Institute in the mail. In order to be eligible to take the class you must meet the following requirements: 1. Must be age 13 or older 2. Parent/Guardian signed Consent form & Release 3. Parent/Guardian signed Waiver & Indemnification Form 4. Must have the following Clothing on the day of class: Long sleeve shirt, Long pants, & over the ankle closed toed shoes Filling out the paperwork does not guarantee your child will be enrolled in the ATV Safety Course. The maximum amount of students per class is limited. *Parent must sign in the Student Signature box. if the Student is under the age of 18.

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6 Dear Parent/Guardian, One or more members of your family, under 18 years of age, are enrolled in the ATV RiderCourse described in the enclosed Student Confirmation Letter. A parent or legal guardian must sign this Consent Form and Release for students under 18 years of age. A parent, guardian or other responsible adult must also attend all lessons for children 6-11 years of age. This Consent Form and Release is for the following family members: IMPORTANT INFORMATION YOU MUST READ AND SIGN THIS CONSENT FORM AND RELEASE The Consumer Product Safety Commission (CPSC) reports that over 3,164 people, including many children, have died in accidents associated with ATVs since Always follow the Manufacturer's Minimum Age Recommendation Warning Label on the ATV. Always supervise riders under 16. Having been advised of the above, the undersigned agrees to release the ATV Safety Institute, the Specialty Vehicle Institute of America, its members, Trustees, employees, agents, representatives, and all other organizations affiliated with the ATV RiderCourse, from any and all liability, loss, damage claim or cause of action, known or unknown, including but not limited to bodily injuries and property damage arising out of participation in the ATV RiderCourse. SIGNATURE (Must be signed by Parent or Guardian if student is under age 18) DATE CONTACT ATV ENROLLMENT EXPRESS AT (800) 887-ATVS OR (800) IF YOU HAVE ANY QUESTIONS. 2 Jenner, Suite 150 Irvine, CA (949)