2013 BFA Jr. Balloonist Hot Air Balloon Camp Camp Registration Form Reno, Nevada

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1 2013 BFA High Sierra Balloon Camp Western States Region Balloon Federation of America Jeff Haliczer, Director Pinion Dr. Reno, Nevada Home Phone: (775) Camp Thank you for your interest in the 2013 BFA High Sierra Balloon Camp in Reno, Nevada which is going to be held on the campus of the University of Nevada, July 21 st 25 th. It is our plan to have the most exciting camp in the history of the BFA Junior Balloonist Camps, which was started in Tyler, Texas back in 2007 and has grown in the number of camps presented across the United States to include camps in Iowa, and in Michigan through the years since. I am pleased to be the Camp Director for the High Sierra Balloon Camp in Reno, Nevada. We have some of the best weather for flying of anyplace I have been, cool mornings and stable weather patterns which will hopefully provide plenty of opportunity for hands on learning about the sport of hot air ballooning. My local team has been meeting and working on the program and fundraising for this adventure and summer experience of a lifetime. The balloon camp program has been listed in the top 10 summer camps by MSN.com ( gallery?photoId=108223) so with that being said, I know we will be able to provide the opportunity to have fun, to learn about balloons and ballooning as a sport, recreation and competition. At this time we expect the cost for camp to be around $425 - $450 and that covers all on site camp costs, housing, meals, off site activities and all materials associated with the camp. I recommend that you contact your local balloon club or event if you live in an area that has one to ask for any assistance or additional funds that you and your family are not able to provide. We will be working hard here in Reno to raise additional scholarship funds to assist the campers. The BFA also has funds available to assist in the tuition for the various camps this year, if you re interested in attending the Reno camp on a scholarship contact the BFA ( and find out the process they have in place for scholarships for the individual camp programs, make sure you tell them that you are interested in the Reno, Nevada - High Sierra Balloon Camp. I am limiting the number of campers to a maximum of 20 so I suggest that your register early, send in your deposit to the BFA (Balloon Federation of America), fill out the registration materials and I will be in touch with additional information as it is needed, I promise to keep you in the loop on details for camp. Let me know if you are going to pre-register so I can hold your spot on one of the crews. Soft Landings and gentle breezes, Jeff Haliczer Camp Director Home (775) (Leave a message if I am not at home, machine is always on) Camp Renoballooncamp@sbcglobal.net

2 2013 BFA Jr. Balloonist Hot Air Balloon Camp Camp Registration Form Reno, Nevada One form for each camper. Please print in Ink Camp Session: Reno, Nevada July 21 st 25 th, 2013 Camper Information Name Last First MI Birthday / / Age at Camp Home Address Street Address City State Zip Home Phone ( ) Grade Completed June 2012 Gender M / F Bunk Buddy (Both campers must list each other to be bunk buddies) Adult T-Shirt Size S M L XL 2X Are you a first time BFA camper? Yes No Parent/Guardian Information Parent/Guardian Name (Required for camp communications) Home Address Street Address City State Zip Phones: Home: ( ) Work: ( ) Cell: ( ) Parent/Guardian Registration Information NOTE: Signature grants permission for camper name, address and telephone number to be released to other campers, and photographs or video images to be used for promotional purposes, unless instructed otherwise by the parent/guardian. Camper s Signature (if 18 or order) Or Parent/Guardian Signature Amount Enclosed $ Check/Money Order # Send this completed form with a minimum non-refundable, non-transferable deposit of $75 for each camper to: BFA Jr. Balloonist Hot Air Camp 2012 Balloon Federation of America PO Box 400 Indianola, IA Make checks payable to Balloon Federation of America. The registration form must be filled out completely and accompanied with a deposit of $75 for each camper in order to register. Registrations are accepted until camp is full. Deposit is non-refundable and nontransferable. The complete registration fee of $425 must be paid in full by May 31 st.

3 2013 BFA Jr. Balloonist Hot Air Balloon Camp Scholarship Application Reno, Nevada (This is the form to submit to the BFA for assistance for the Camp Fee/Tuition ) Requirements: Age requirement: Write a minimum 500 word essay on ONE of the following topics: Why you want to attend the BFA Balloon Camp What the sport of ballooning means to you A written recommendation, by a parent, teacher or someone associated with ballooning. Enclose this person s contact information with the application. Application Deadline: Application Award: May 1st May 31st Applications must be received by the Application Deadline of May 1 st. Applications will be reviewed by the BFA Jr. Balloonist committee, and you will be notified of the decision by on May 31 st, or shortly after by USPS if no is available. Applicant Information: Name: Street: City, State, Zip: Phone: Date of birth: address: Parent Name: Parent s Signature: ( ) / / (month / day / year) Recommended by: Name: Association (Circle): Parent Teacher Pilot Other: Street: City, State, Zip: Phone: ( ) Mail essay, recommendation and scholarship application to: BFA Jr. Balloonist Camp Scholarship Balloon Federation of America P.O. Box 400 Indianola, IA All awards must be used in the year awarded. Payment of scholarship will be made directly to the BFA Camp. If the recipient is unable to attend camp for the year it is awarded, the scholarship will be forfeited.

4 2013 BFA Jr. Balloonist Hot Air Balloon Camp Scholarship Application/Essay Reno, Nevada (This is the form to submit to the BFA for assistance for the Camp Fee/Tuition ) Write an essay on ONE of the following topics: Why you want to attend the BFA Balloon Camp What the sport of ballooning means to you Use the space below and/or attach your essay to the application. Camper Signature

5 2013 BFA Jr. Balloonist Hot Air Balloon Camp Health History Form Reno, Nevada One form for each camper/volunteer. Please print in Ink The information in this form is to assist your camp staff in identifying appropriate care. If under 18 years of age, a parent/guardian should fill out pages 1-3. Any changes to this form should be provided to the camp staff upon check-in at camp. This form may be photocopied for your convenience. Camper Name Birthday / / Last First MI Age at Camp Home Address Street Address City State Zip Home Phone ( ) Gender M / F Parent/Guardian Name Home Address Street Address City State Zip Phones: Home: ( ) Work: ( ) Cell: ( ) Second Emergency Contact Name Home Address Street Address City State Zip Phones: Home: ( ) Work: ( ) Cell: ( ) Camper Signature: I agree to abide by any restrictions placed on my participation in camp activities by my physician, or parents/guardian as described here: Signature of camper Date Parent/Guardian signatures required for attendance Parent/Guardian Authorization: This health form contained herein is correct as far as I know and the camper has permission to engage in all camp activities except as noted. In the event I cannot be reached in an emergency, I hereby give permission to the medical provider selected by a designated representative of the Balloon Federation of America to authorize emergency medical or surgical treatment, routine, non-surgical medical care, hospitalize, secure proper anesthesia, or to order injection(s) for my child. The person herein described is in good health, has all required immunizations current, and I assume the health responsibility for the individual. Health Care: I give the camp staff permission to give my child over-the-counter and prescription medications in accordance to prescribed instructions. Emergency Authorization: I give permission to the medical personnel to order X-rays, routine tests and treatment for my child, in the event I cannot be reached in an emergency. I give permission to the medical personnel to hospitalize, secure proper treatment and to order injections and anesthesia and/or surgery for my child. This form may be photocopied for use with medical personnel. Transportation Authorization: I give permission for my child to be transported in a private vehicle, if necessary. Liability Release: It is understood that the activities of the camp will include crewing and tethering in hot air balloons, and travel in private vehicles. The attendees and parents undersigned release the sponsors, officials, employees, and volunteers of the Balloon Federation of America and Albion College from any and all claims or liability in connection with the events of the BFA youth balloon camp. The attendee and parents agree that this release and waiver agreement is intended to be broad and inclusive as permitted by the State of Michigan, and that if any portion thereof is held invalid, it is agreed that the balance shall continue in full legal force and effect. Camper s Signature (if 18 or order) Or Parent/Guardian Signature Date Printed Name

6 Health History The following information must be filled in by the parent/guardian, or adult camper or staff/volunteer member. Insurance Information: Is the camper covered by family medical/hospital insurance? Yes No Carrier and Plan Name: Policy or group number Please attach a copy of your insurance card. Describe dietary or activity restrictions: Allergies List all known Reaction and management of reaction Medication allergies (Penicillin, etc.) Insect bites/stings Food allergies Other allergies Medications: Check here if this person takes no medications on a regular basis. List all medications taken on a regular basis or that camper will bring to camp. Prescription medication must be brought in original container. The dosage/frequency schedule identified by the physician will be administered by camp staff. Bring enough medication to last the entire camp session. It is not recommended that extra medication be brought to camp. Leave gray area blank for camp staff s notes. It is recommended that all medication used during the school year is also used during camp week. Please do not use this time to test your child's routine. #1 Medication Dosage Specific time Reason for taking #2 #3 #4 #5 #6 The camp staff can provide my child with these over the counter medicines if necessary: Tylenol Motrin/Advil Tums Benadryl None Are there any over the counter medications that should NOT be administered?

7 Health History Primary Physician Name Dentist Name Phone ( ) Phone ( ) Medical Conditions Circle One Medical Conditions Recent injury, illness or infectious disease Y N Heart Defect/Disease Y N Chronic or recurring illness/condition Y N Mononucleosis in the past 12 months Y N Autism ** Y N Ever had emotional difficulties for which professional help was sought Y N ADD or ADHD ** Y N Bleeding/clotting disorders Y N Diabetes Y N Wears glasses, contacts or protective eye wear Y N Asthma Y N History of sleep walking Y N Has or had an eating disorder Y N Uses wheelchair or walker ** Y N Seizures Y N Other: Y N Please assist us so we can provide the best camping experience for your child! If ** is indicated, please contact the camp director One month prior to the camp to assist us with our staff and room assignments. Provide an explanation for all questions to which you answered Yes to above or any other condition of which you feel the camp staff should be aware. Circle one Immunization History (date of most recent immunization) Tetanus / / Measles / / Polio / / Rubella / / Mumps / / Hepatitis B / / Diphtheria / / TB Test / / Pertussis / / Result of last TB Test (circle one) Positive Negative FOR CAMP PERSONNEL Arrival Day Check-in 1. Emergency authorization on page one of this form signed? Yes No 2. Been exposed to any contagious disease in the last two weeks? Yes No If yes, please explain 3. Brought over the counter or prescription medications Yes No Additional medication form needed to list additional meds? Yes No (A camp staff member will need to record ALL medications brought to camp.) 4. Medical/social/physical condition of which camp staff should be informed? Yes No If yes, please explain Staff member's initials Information received from: Mother Father Grandparent Camper Other Date, if different than registration date

8 2013 BFA Jr. Balloonist Hot Air Balloon Camp Camper Questionnaire Reno, Nevada (This is to be returned to the Reno Camp Director) This questionnaire is to better understand the experiences and expectations of the campers. The more we know about the campers, the better we can try to make sure you enjoy your Hot Air Balloon Camp experience. Please take time to fill this out as best as possible and return it to the camp director as soon as possible. Camper Name: About how many years have you been crewing? Have you ever flown in a Hot Air Balloon? Yes No Have you ever flown in an airplane? Yes No About how many times have you crewed for a balloon? (Check one) None yet 1 15 times More than 15 times What types of crewing have you experienced? (Check all that apply) Fun Flight Competition Paid Riders Engagement Flight Special Shapes (fill in the blank) How did you get interested / started in ballooning? Family Friends Saw one flying Went to a balloon rally (fill in the blank) About how many different pilots have you crewed for? (Check one) One 2 3 Several different pilots

9 What type of balloon systems have you crewed on? (Check all that apply) Cameron / Lindstrand Aerostar Firefly / Balloon Works (fill in the blank) I don t have any idea What subject do you enjoy the most in school? Math Reading / Language History Science Art What interests you the most about Hot Air Balloon Camp? What would you like to learn at Hot Air Balloon Camp? Would you like to become a Hot Air Balloon Pilot? Yes Thinking about it No Mail this directly to me no later than June 10, 2013 to help with planning: Jeff Haliczer Camp Director High Sierra Balloon Camp Pinion Dr. Reno, Nevada 89521

10 2013 High Sierra Balloon Camp Balloon Federation of America - Western States Region Jeff Haliczer, Director Pinion Dr. Reno, Nevada Home Phone: (775) Camp Renoballooncamp@sbcglobal.net Photo Release - Permission to Use Photograph Event: High Sierra Balloon Camp of the Balloon Federation of America Location: Reno, Nevada and associated locations I hereby release High Sierra Balloon Camp and the Balloon Federation of America to use any photograph, including pictures, videos, DVD s or other media that have been taken in conjunction with the High Sierra Balloon Camp, without any compensation expressed or implied. I grant to the High Sierra Balloon Camp and the Balloon Federation of America, the right to take photographs of me, or minor child and my family in connection with the aboveidentified event. I authorize High Sierra Balloon Camp and the Balloon Federation of America, its assigns and transferees to copyright, use and publish the same in print and/or electronically I agree that High Sierra Balloon Camp and the Balloon Federation of America may use such photographs of me and or my minor child with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, social media, associated web sites and Web content. I have read and understand the above: Signature Printed name Address Date Signature, parent or guardian (if under age 18)