2019 Registration Form

Transcription

1 Please include a $50 NONREFUNDABLE DEPOSIT for each camp. Please complete a separate form for each camper. For Office Use Only Please Print Legibly Parent/Guardian Information Relationship to Camper Relationship to Camper Title First Name Last Name Cell Phone Work Phone Title First Name Last Name Cell Phone Work Phone Home Phone Camper Information Home Phone First Name Last Name Gender: Male Female Date of Birth / / Age: Grade in September 2019: Home Address_ City State Zip code T-Shirt Size: Youth/Child: Small Medium Large X-Large Adult: Small Medium Large X-Large Emergency Contact Information This person will be contacted if the Parent or Guardian is unavailable. Other than the 2 guardians listed above, and the emergency contact, please list other adults who may pick up this camper in the Release of Minors area below. Name Relationship to Camper _ Phone Release of Minors All Campers are released at the end of camp to their parent/guardian (listed above), emergency contact or one of the individuals below. NO EXCEPTIONS. Please be advised that photo identification and camper pickup ID card must be provided at time of pickup. Name Relationship to Camper _ Phone Name Relation ship to Camper _ Phone Name Relation ship to Camper _ Phone Parent/Guardian Signature _ Date 1

2 Parent /Custodial Issues Check here if there are any unresolved legal parent/custodial issues that Camp Harlow needs to be aware of. NOTE: If you have a working parenting plant, that does not necessarily constitute marking this box. Marking this box will initiate a request for more documentation. Please call the Camp Harlow office with any questions If you marked YES, please explain: Additional Information Cabin Buddy* for overnight Camps ONLY *This is a REQUEST and not a guarantee 1st Choice 2nd Choice Housing Information- for overnight Camps ONLY Cabin Covered Wagon (Wagons are not available for High School Camp) Camp Information Please select which camp(s) you would like to register for. DAY CAMPS- Ages 5-9 Regular Care 8:30-3:30 Extended Care 7:45-5:30 Spring Break Camp- March Regular Care $155 Extended Care $175 Day Camp 1-July 8-12 Regular Care $235 Extended Care $265 Day Camp 2-August 5-9 Regular Care $235 Extended Care $265 Day Camp 3-August Regular Care $235 Extended Care $265 OVERNIGHT CAMPS Grades 1-5 Elementary Overnight EON June19-21 $205 Grades 3-5 Junior Overnight JR1 June 30-July 3 $219 JR2 August $284 Grades 5-7 Tween Overnight TW1 July $354 TW2 August $354 Grades 6-8 Middle School Overnight MS1 June $379 MS2 July 28-August 2 $379 Grades 9-12 High School Overnight HS July $389 2

3 Additional Options The Camp Store and Café are available for all ages and are an additional opportunity for campers to enjoy while they attend Camp. The students attending our Tween, Middle School, and High School camps have the opportunity to add paintball to their experience for an additional fee. Camp Store & Cafe Please select all that you desire $10 $15 $20 $30 Donate the remaining Camp Store Balance to the Scholarship Program Paintball Please the number of Games you would like to play (Eligible camps are Tween, Middle & High School) 1 Game $20 Media Team or Cabin Photo $8 Camp Video, Online Delivery $15 Combo Cabin Photo and Video $20 Help Sponsor another Camper Please select the all that you desire $5 $10 $25 Other $ Total (Including the camp and any options selected above) $ Payment Information Minimum $50.00 deposit is required per camp. (This is NONREFUNDABLE and is a part of the total camp fee) Total enclosed $ Payment method: Check Cash Visa MasterCard Other (AMEX/Discover) Check Number Please Charge my credit Card: Number Expiration Date / CVV Billing Zip Code Print Name Signature 3

4 Camper Information Does your Camper have any special interests/activities that he/she especially enjoys? To help set your camper up for success, it here any additional information that would be pertinent for the counseling staff to know about your camper? Please let us know below: How did you hear about Camp Harlow? Medical Information Does your camper have any known Allergies? Yes No Please list below any known allergies and list treatment and details for them. Allergies: Details and Treatment: Does your Camper have any Dietary Restrictions? Yes No Please list below any known allergies and list treatment and details for them. 4

5 Instructions for Medications at Camp Harlow All Medication must be turned in to the nurse at registration. DO NOT pack any medication in your camper s luggage. All Medication must be in its ORIGINAL containers with the Camper s name and instructions. (You may ask your pharmacist for an extra container) Please bring exact number doses plus one for time at camp. *No need to bring acetaminophen, ibuprofen or aspirin. Sample medications will be accepted with a doctor s note authorizing the medication with dosage and instructions. All medication is kept in the Nurse s station and is administered there. Campers who need emergency inhalers or epi-pens may carry them. You may choose to leave these with the nurse. If not, you must leave a backup supply at the Nurse s station, one with camper, one with nurse. Over the counter medications are not accepted. Please see the list on the following page of the over the counter medications that are on hand. Medication Information Name of Medication Dosage Time Reason for Medication Camp Harlow must be made aware of any special needs or considerations at minimum of 2 weeks prior to the camp. Please list any current medical conditions or concerns, any recent injury, or limitations to activities at Camp 5

6 Doctor and Insurance Information This person will be contacted if the Parent/Guardian or Emergency Contact are not available Family Doctor Name Phone Number Health Insurance Company Date of last Tetanus Shot / / (A tetanus shot is required) Over the Counter Medications Please mark any medications that you DO NOT want your child to have. The Camp Harlow consulting physician has issued standing orders permitting the dispensing of common over the counter medications. These will be dispensed as needed. DO NOT send these medications with your camper. Also, please mark any medication that you DO NOT want your child to have. Non-aspirin pain reliever (Tylenol or generic) Ibuprofen (Advil or Motrin) Antacid (Mylanta or Tums) Antihistamine (Bendadryl, Loratadine, Cetirizine) Cough Syrup (Robitussin DM) Decongestant (Sudafed PE) Imodium (for Diarrhea) Pepto Bismol Melatonin 6

7 Health History Information Please review the following list and note if they have any of the following medical conditions and how they are treated. Conditions No Yes Unknown Details Asthma Diabetes Physical Needs or Challenges Developmental Delays Behavioral Concerns Emotional Concerns Social Concerns, or concerns with interactions Needs Specific Redirection Activity Restrictions Special Assistance Other Medical Challenges Other Needs Do you require our Medical staff to follow up with you? Yes No 7

8 Parental Release AUTHORIZATION OF TREATMENT I, the parent or legal guardian of the listed camper, hereby give permission to Camp Harlow to administer medication as previously listed. I understand that it is my responsibility to provide prescription medication in original pharmacy containers or as labeled physician samples. I understand that if my camper requires medical attention in additional to the described above, that Camp Harlow will attempt to contact me first. If I am unavailable, I authorize Camp Harlow to contact my camper s physician. If neither I nor my child s physician. If neither I nor my child s physician is available, I authorize Camp Harlow and First Baptist Church to order X-Rays, routine tests, and treatments ; to release any records necessary for insurance purposes; and to provide or arrange transportation for my camper to a nearby clinic or hospital. I will hold harmless Camp Harlow, its staff and the First Baptist Church of Eugene, and its pastors from any claim of liability arising from attending camp. PHOTO/VIDEO RELEASE INFORMATION During our camp sessions, the Camp Harlow Staff takes photo and videos for cabin or team photos, daily videos, slide shows and promotional purposes. If there are reasons that your child should not be photographed or on video, please contact the Camp Harlow Office at at your earliest convenience. ACTIVITIES & TRAVEL RELEASE I, the parent or legal guardian of the previously listed camper, hereby give permission for my camper to travel to and participate in offsite Camp Harlow Middle School or High School activities such as Breakfast on the Butte, Service Projects, and Lake Day. I, the parent or legal guardian of the previously listed camper, hereby give permission for my camper to participate in onsite Camp Harlow activities such as; Zipline, Big Swing, Challenge Course, Intensity Bridge, Flying Squirrel, Canoes, Fort Hawk, Inflatables, Rockwall, Archery, Swimming Pool, Go Carts, Fire Truck Rides, and Train Rides. I, the parent or legal guardian of the previously listed camper, hereby give permission for my camper to ride and or be around horses at Camp Harlow. Signature of Parent/Guardian Printed name of Parent/Guardian Date NOTE: by initialing and signing above, you acknowledge that you have read and agreed to each item. 8