HEALTH EXAMINATION FORM CAMP GLEN ARDEN P.O. BOX 7 Tuxedo, NC (828) THIS SIDE TO BE COMPLETED BY PARENTS

Transcription

1 HEALTH EXAMINATION FORM CAMP GLEN ARDEN P.O. BOX 7 Tuxedo, NC (828) THIS SIDE TO BE COMPLETED BY PARENTS Camper s last name: First Name MI DOB Home Address Parent/Guardian Home Address (if different from above) Home Phone Cell Phone Business Phone Home Phone Cell Phone Business Phone IF PARENT/GUARDIAN NOT AVAILABLE IN CASE OF EMERGENCY, NOTIFY: 1. Name Relationship to camper Home Phone Cell Phone Business Phone 2. Name Relationship to camper Home Phone Cell Phone Business Phone Camper s Health History: Medical problems Activity you want restricted Any special considerations Other health information you feel is important (allergies, current medications, etc.) IMPORTANT: Please notify camp if exposure to head lice or infectious disease occurs within 3 months prior to camp. If camper wears glasses, please send an extra pair as well as prescription. If camper has braces, send a good supply of all materials. An extra retainer is recommended. REQUIRED INSURANCE INFORMATION: Please send copy of insurance card, include both front and back. Write cardholder s date of birth on copy sheet. AUTHORIZATION: This information is correct to the best of my knowledge and the above named individual has permission to engage in all camp activities, except as noted by the examining health care provider or me. I give permission for camp to provide and/or secure medical treatment for my child. I accept responsibility for any medical expense involved. Parent/Guardian NOTE: Reverse side to be completed by Health Care Provider 1 Date

2 THIS SIDE TO BE COMPLETED BY HEALTH CARE PROVIDER Camper s Name: Medical/Surgical History Immunizations: Give date of series completion or last booster: DPT MMR Polio Hep B HIB Tetanus Vericella or Chicken Pox TB test Neg/Pos; treated if Pos: Yes No No Yes Please provide appropriate detail if yes Allergies food, insects, and/or medication Anesthesia problems for camper or family Asthma Bed wetting Diabetes Eating Disorder Periods Started Previous Surgery Psychiatrist/Psychologist Care Restricted Activity Serious Injuries Seizures Special Diet/Vegetarian Other chronic illness or health problem Current prescription medication(s) with administration directions: Other information to facilitate care while at camp: Physical Exam (Examination within 6 months before arrival at camp is acceptable): Ht Wt BP Vision R L U/A (if done) Hct (if done) General Appraisal HEENT Skin/Hair/Nails Heart Lungs Abdomen Extremities Spine Normal Abnormal Please provide appropriate detail if abnormal I have examined this person and reviewed her health history. Except as noted above, she is able to engage in any and all camp activities. / / Provider Printed Name Signature Date Address 2 Phone

3 Travel Information Please return this form to Glen Arden by May 15 th. If the camper is traveling by air, please give us full details including all intermediate stops. If the camper is arriving and departing by car, please include the name and relation of the driver. Camper s Name: Traveling to camp by: 1 st Leg: Car/plane Arrival Date: 2 nd Leg: 3 rd Leg: Baggage will be sent by: Car/plane/UPS Arriving with: Name of Person, if by car Traveling from camp by: 1 st Leg: Car/plane Departure Date: 2 nd Leg: 3 rd Leg: Baggage will be sent by: Car/plane/UPS Departing with: Name of Person, if by car

4 Camp Glen Arden Policy Statement Glen Arden is a community based on shared experiences and simple living. We do not have worldly music, world news, or worldly cares such as traffic, commercialism, or pollution of any kind. We work toward these ends in thought and deed. In order for us to achieve this, we ask for your cooperation. Camp is a time to make new friends and meet people from new places. We assign campers to cabins with preference being given to those friendships formed at camp. No more than two friends from the same hometown will be placed together. We must receive in writing requests from both families in that regard three weeks prior to the beginning of the session. The assignments will be determined by the Camp Director, and decisions are final. We ask that you review our No Package Policy. Campers are welcome to bring with them summer reading, a stuffed animal, a small toy or game. Cell phones, magazines, comic books, CD players, MP3 players, radios, tablets, computers, TVs, or electronic games should NOT be brought or sent to camp. They will be collected and kept in the camp safe until camp is over. Do NOT send any food items including gum to camp; any food items found will be taken from the camper. Camper signature: Parent signature: This Policy Statement and the Health Form must be signed and received in the office no later May 15 th, 2016 for the camper to attend.

5 CAMP GLEN ARDEN P.O. Box 7 Tuxedo, NC This summer, we will again allow parents to e- mail their daughters at camp. The camper e- mail address is campglenarden@gmail.com, with your daughter s full name and cabin in the subject line. This is a one way system; the girls will not be able to respond by e- mail. There will be a $1 charge for each e- mail received, printed, and delivered. This will be charged to the camper s canteen account. E- mails must be received by 10:00 am in order to be delivered the same day. E- mails received after 10:00 am will be delivered with the next day s mail. On the next page is a form for you to give us up to four e- mail addresses. E- mails received from addresses not on this list will not be printed or delivered to your camper. By signing this form, you give us permission to charge her canteen account $1 for each e- mail received, printed, and delivered. You can certainly give us fewer than 4 addresses, and can choose to opt out of the e- mails entirely. PLEASE NOTE: We will not be receiving camper e- mails at our office e- mail address. In order to better manage the intake, camper e- mails MUST be sent to campglenarden@gmail.com. In the subject line, please write the camper s name and cabin number. It is our hope that this new policy will allow you be in touch with your daughter in a timely and efficient manner. It is not our intention for e- mails to replace a handwritten letter, which your daughter will treasure for years to come.

6 Camp Glen Arden Policy Camper Name: Parent Name: The camper e- mail address is E- mails must list the camper s full name and cabin number in the subject line. Parents may choose up to 4 e- mail addresses that they will allow send e- mails to their camper during the summer. By listing the addresses below, I agree to a charge of $1 per e- mail received by campglenarden@gmail.com and delivered to my camper. (Please print clearly) E- mail Address 1: E- mail Address 2: E- mail Address 3: E- mail Address 4: I do not wish to participate in camper e- mails. Please do not print out any that might be received. Parent Signature:

7 Camper Questionnaire Summer 2016 Dear Camp Glen Arden, My name is. I am in the grade. I am attending the session. June, July, Tajar Time 1, Tajar Time II These are some of the things that I like to do: My friends describe me as: I am looking forward to these things at camp: How would you describe the perfect counselor? I am most nervous about: The following are some camps I have been to before: See you soon, (Full Name) P.S. I also wanted you to know:

8 The UPS Store Camper Shipping Form 2016 Camper Information: Camp Name Session Start Date Camper Name Session End Date Round Trip? D Yes D No Shipments using our store to ship both to and from camp receive a 10% discount. This offer is only valid through The UPS Store 4054 in Hendersonville, NC. Campers shipping only from camp do not need to provide a ship from address. When shipping to camp, for an additional $15.00 fee, arrangements can be made for UPS to pick up the package(s) from the location of your choice or they can be dropped off at any UPS location. UPS Pick-Up 0Yes 0No Ship From Ship To Contact Information: Parent Address (for labels and receipts) Box? D Yes 0No Insurance (Declared Value) Boxing a trunk is $ Boxes are required to receive insurance benefits. All Boxed Shipments are insured for $ You may choose to add insurance to your shipment, the cost is $2.00 per $ of coverage. Unboxed items will not be able to carry insurance, and will not be reimbursed in the case of damage or loss. Number of Shipments (trunk, duffie, bag, etc.) For a shipment, if actual dimensions are not available, rates are calculated based on 34x16x16 and 60 lbs for a trunk, and 30x17x16 and 45 lbs for a duffle. If the size/weight is different upon arrival, the cost will be either credited or debited to your card accordingly. D Overnight D 2 Day Air D 3 Day D Ground (3-5 days) Processing can take up to 2-3 days before being shipped out. If you need the trunk expediated, please chose the appropriate option, or leave specific directions in the comments section below. Billing Information: Credit Card # Expiration CV Code Billing Zip Code Please sign below to verify that you have read and understand the terms of this form and authorize The UPS Store of Hendersonville to charge your credit card th er Comments Thanks For Letting Us Take Care of Your Shipping Needs! The UPS Store Brevard 638 Spartanburg Hwy, Ste 70 Hendersonville, NC Phone Fax store4054@theupsstore.com

9 Additional Statements of Waiver TO: Camp Glen Arden, LLC, a North Carolina limited liability company I understand that there are inherent risks involved in my daughter s participating in summer camp activities sponsored by Camp Glen Arden, LLC ( Camp Activities ). I also understand that the risks associated with Camp Activities are beyond the control of Camp Glen Arden, LLC and its employees. I, my spouse, my child, and my and my child s heirs, successors, assigns and personal representatives hereby, to the fullest extent permitted by applicable law release and discharge Camp Glen Arden, LLC, its representatives, agents, employees, officers, directors, volunteers, and successors and assigns (hereinafter referred to individually or collectively as Released Parties ) from any liability or causes of action whatsoever arising from, or on account of, property damage, economic loss, or personal injury or death, related to or resulting from my child s participation in the Camp Activities, including, without limitation, any liability or causes of action based on or caused by the negligence of the Released Parties or any other persons. Signature of Parent or Legal Guardian: Date: / / TUITION REFUND POLICY There will be no reduction of fees for late arrivals or early withdrawals, including homesickness. Only in cases of early withdrawal due to serious illness will a refund of a portion of the tuition be considered. Camp Glen Arden, LLC reserves the right to dismiss any girl whose presence or actions, in the Director s judgment, are detrimental to the best interests of Camp Glen Arden, LLC, and the summer camp experience it offers. In the event of any such dismissal, there will be no refund of any camp tuition. I have read and agree with the terms of enrollment as stated within this document. Signature of Parent or Legal Guardian: Date: / /