Tennessee Valley Railroad Museum Rail Camp

Transcription

1 Tennessee Valley Railroad Museum Rail Camp Please complete ALL information and return by May 1st. Incomplete forms will not be processed. Camper Name: Preferred Name: (First Name) (Middle Initial) (Last Name) Birthdate: Gender: (MM/DD/YEAR) Address: City: State: Zip Code: Home Phone: Cell Phone: Camper s Address: Grade in fall of 2018: School attending in fall: Camp Session (please circle): Session 1 - May 29-June 2 Session 4 - June (Day Camp, 7-9 years old) (Overnight, years old) Session 2 - June 4-9 Session 5 - June (Day Camp, years old) (Overnight, years old) Session 3 - June (Day Camp, years old) Circle summers child has attended TVRM Rail Camp: TVRM Member: No Yes (please circle one Student, Individual, or Family) 1st Parent/Guardian s Name: Preferred Phone: Address (if different from camper) Address:

2 2nd Parent/Guardian s Name: Preferred Phone: Address (if different from camper) Address: Camper resides with: 1st Parent/Guardian 2nd Parent/Guardian Both Joint Custody Check here if there are special custody circumstances (restricted parental access, lives with other than legal parent/guardian, etc.) Please include copies of all appropriate legal forms with application. Please include any additional information about campers living situation that may helpful for staff to know (recent move, divorce/death in the family, sibling moving on to college/other, change of school, etc.) Emergency Contact Information Please be sure that this person knows your child well enough to act in your place in the event you cannot be reached in the event of an emergency! Name: Relationship to Applicant: Telephone Number(s): Is there anyone else who is authorized to pick-up this camper? No Yes If yes, please list name and relationship to student: *Any special instructions, such as custody or restraining orders, must be attached to this application and discussed personally with the camp director. All information will be kept confidential.

3 This year we are offering several different options to fine tune camper s experiences at camp! Campers will be placed in Modules as space is available, and at the staff s discretion. Please rank the following Modules in order of your camper's preference (1 = Most Interested in - 10 = least interested in: Locomotive Operations Experience - Shadow our engineers and learn about the skills needed to operate Steam and Diesel locomotives. Passenger Operations Experience - Shadow our conductors and learn about their onboard duties. Shop Work Experience - Spend extended time in our restoration shop, learning about the process of restoring and maintaining vintage railroad equipment. Track-Work Experience - Learn the importance of track work. Ride a velocipede and track speeder! Intro to Railroad Modeling - Learn the skills involved in designing and building model railroads. Intro Pullman Service - Shadow our Dining Car staff and learn how on-board meals are prepared, and how a fine dining experience for our passengers is possible. Photography - Learn to compose, shoot, and edit still and action shots of railroading interest. Blacksmithing - Spend extended hands-on time working in our on-site blacksmith s shop. Chattanooga Railroad History - Learn then history of railroading, specific to the Chattanooga area. Participate in extra field trips to local sites of interest. Rail Fanning - Gain access to local sites to watch, photograph, and film trains.

4 MEDICATION INFORMATION: Camper s Pediatrician: Phone Number: Date of last Physical: (Must be within the past year) Does camper regularly take medications during the school year to aid in focus/attention? No Yes (if so, we encourage continued use during camp session, with physician s approval) Please list all the camper s current medications (regardless of whether it needs to be taken a camp or not): Name of Medication Dosage Additional Information Administered at Camp? (Y/N) Are there any medications that your child will be required to take while at camp? No Yes If yes, please give specifics - names, description of the medication (color of pill/liquid/etc.), when they are to be taken, and if the medications need to be refrigerated. All medications must be provided in daily dose containers, labeled clearly with the camper s first and last name. Name of Medication Dosage Description (color, shape, etc.) Additional Information Please note that there is an extended Medical Form attached with this application that must also be filled out

5 To assist Rail Camp staff in providing the best possible camp experience for your camper, please answer the following questions as carefully and completely as possible: Has your camper been to a day camp before? No Yes Where and for how long? Has your camper been to an overnight camp before? No Yes Where and for how long? Does your camper wear glasses or contact lenses? No Yes Does your camper have any allergies? No Yes If yes, please specify: Does your camper have any dietary needs? No Yes If yes, please specify: Does your camper have any special mobility needs which may require modifications to be made by camp staff? No Yes If yes, please specify: Has your camper been given a Autism Spectrum related diagnosis? No Yes If yes, please explain: Does your camper have any physical, learning, language, developmental, emotional, or behavior difficulties and/or differences which may require modifications to be made by camp staff? No Yes If yes, please specify: Can your camper follow three step instructions without further prompting? No Yes Please describe your camper s fine motor skills: Please describe your camper s gross motor skills: Does your camper make new friends easily? No Yes Does your camper enjoy being outdoors, exercising, and being active? No Yes Does your camper participate in any sports or other outdoor actives (camping, hiking, boating, etc.)? Please list: Does your camper enjoy indoor activities in climate controlled environments? No Yes

6 Does your camper enjoy artistic and/or hands on creative projects (such as drawing, painting, playing musical instrument, woodworking, railroad modeling, etc.)? No Yes Please list: Can your camper walk 1-2 miles on level ground without tiring? No Yes Does your camper swim in water over their head? No Yes Can your camper climb a ladder unassisted? No Yes Is your camper easily embarrassed or upset? No Yes Does your camper become angry or aggressive when challenged by peers? No Yes If yes, please describe: Does your camper exhibit any attention seeking behaviors? No Yes If yes, please describe: Is there anything your camper may be nervous about at camp? No Yes If yes, please specify: Does your camper need any assistance in remembering to perform daily self care (toothbrushing, clean clothing, etc.)? No Yes If yes, please specify: Does your camper exhibit people pleasing behaviors that may require staff to help them stand up for themselves among peers? No Yes If yes, please specify: What is your camper most looking forward to about Rail Camp? Does your camper have any concerns about attending Rail Camp? Is there anything else you can tell us about your camper to help enable Rail Camp staff in providing the most safe, accessible, and enjoyable experience for them?

7 TVRM RAIL CAMPER S AGREEMENT I understand that I must conduct myself in an appropriate manner both at the Museum and when I am out in public. I will show appropriate respect for camp staff, other campers, as well as Museum staff and guests. I will show respect for Museum property and grounds, as well as any other locations we may visit. If I do behave in any way that camp staff does not believe to be appropriate, my legal guardian will be called and I will be sent home. If this occurs, no refund will be given. I understand that there is a dress code I must follow in order to participate in summer camp. This dress code includes long jeans, and sturdy shoes with good soles (No open toed shoes). I understand that if I do not adhere to this dress code I will have to sit out of certain activities. I understand that The Tennessee Valley Railroad is an operating railroad with running equipment. Therefore during the day I may get dirty, wet, oily, or greasy and I will not wear anything that I do not want ruined. I understand that phone contact with campers is not available with campers for the duration of the session. I understand that due to camp rules, and in some cases Federal Regulations, the use of cell phones, pagers, music players, handheld game machines, tablets, laptops, or other electronic devices are not allowed at TVRM Rail Camp. If the camper does bring one of these devices, staff will collect them, at their discretion, for the duration of the camp session. TVRM will not be responsible for any such devices that are lost or damaged. Camper: Date: Legal Guardian: Date:

8 RELEASE/CONSENT/ACKNOWLEDGMENT/ASSUMPTION OF RISK: I/we, the undersigned parent(s) or guardian(s) of the camper named in this application (hereinafter referred as the Child ), acknowledge that we are aware of the types of activities in which the Child will be participating during his attendance at the summer camp session at the Tennessee Valley Railroad Museum, and that we have been given ample opportunity to ask any questions which we may have about the environment at the Museum and the activities in which the Child will participate. I/we are aware of the dangers which are inherent in the operations of any children s camp and in the Child s participation in all camp activities, either on or off the premises of the Museum, which may include use of tools and equipment in shop work; washing, cleaning, and preparing railroad cars for use by the Museum; riding in the cab of a locomotive engine; painting; oiling, greasing, and/or otherwise servicing locomotive engines and rolling stock; engaging in camp activities which involve physical contact with other camp attendees involved in the same activity; as well as vehicular travel. I/we further acknowledge that I/we have given the Tennessee Valley Railroad Museum full disclosure of any pre-existing physical or mental limitations, challenges, or problems of which we are aware. Because of the potential dangers inherent in participating in the activities of any children s camp, I/we recognize the importance of the Child s obeying the instructions of camp employees and abiding by all camp rules and regulations. I/we have instructed the Child to obey all instructions from camp employees and to abide by the rules and regulations of the camp, and I/we do hereby release the Tennessee Valley Railroad Museum and its officers, directors, staff, counselors, and other employees from any liability which they might otherwise incur as a consequence of the failure of the Child to obey said employees and abide by the rules and regulations of the Museum, and from any other liability which the Museum and the individual parties listed above might otherwise incur in incidents involving the Child s negligence or contributory negligence. PHOTOGRAPHS: I/we grant permission to the use of photographs or video that includes pictures of my/our Child for camp advertising and promotion in Museum brochures or on the Museum website. I/we understand that the Museum intends to provide children with cameras to use to photograph and document camp activities during the entire camp session, and I/we acknowledge that the Museum retains all right of ownership to all photographic images generated in this process. I/we also understand that copies of photographs will be given to camp attendees. APPROVAL AND PAYMENT: I/we have read the information in this application and agree to its terms. Not later than May 25, 2018, I/we will send a check for the full summer camp fee. I/we understand that the summer camp fee is non-refundable after payment and that there will be no refund for cancellations occurring after May 25, Date: Signature of Parent/Legal Guardian Date: Signature of Parent/Legal Guardian If only one parent/legal guardian has signed, the Tennessee Valley Railroad Museum will presume full parental consent unless the Museum is expressly instructed otherwise.

9 CAMPER HEALTH HISTORY FORM1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Mail this form to the address below by (date) Camper Home Address: Street Address City State Zip Code Parent/guardian with legal custody to be contacted in case of illness or injury: Relationship Name: to Camper: Preferred Phones: ( ) ( ) Home Address: (If different from above) Street Address City State Zip Code Second parent/guardian or other emergency contact: Relationship Name: to Camper: Preferred Phones: ( ) ( ) Additional contact in event parent(s)/guardian(s) can not be reached: Relationship Name: to Camper: Preferred Phones: ( ) ( ) Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe below what the camper is allergic to and the reaction seen.) Diet, Nutrition: Restrictions: Medical Insurance Information: This camper eats a regular diet. This camper eats a regular vegetarian diet. This camper is lactose intolerant. This camper is gluten intolerant. Other, please explain in space. I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.) This camper is covered by family medical/hospital insurance Yes No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable. Insurance Company Subscriber Parent/Guardian Authorization for Health Care: Dates will attend camp: from to Camper Name: First Middle Last Male Female Birth Date Age on arrival at camp: To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. 1) Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy. 2) Send the original, signed FORM 1 to camp by the requested date. 3) Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the copy of FORM 1 with FORM 2 to your child s health-care provider for review and completion. 4) After it has been completed and signed by your child s health-care provider, return FORM 2 to camp by the requested date. Policy Number InsuranceCompany Phone Number ( ) This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a need to know basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. Signature of Custodial Relationship Parent/Guardian Date: to Camper: If for religious or other Summer reasons Camp you cannot Application sign - this, 2018contact the camp for a legal waiver which must be signed for attendance. Page 1/4 First Middle Last Camper Name (For Camp Use) Cabin or Group (For Camp Use) Session Code(s):

10 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: Immunization History: Provide the month and year for each immunization. Starred ( ) immunizations must include date to meet ACA Standard. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form. Immunization Dose 1 Month/Year Diptheria, tetanus, pertussis (DTaP) or (TdaP) Tetanus booster (dt) or (TdaP) Mumps, measles, rubella (MMR) Polio (IPV) Haemophilus influenzae type B (HIB) Pneumococcal (PCV) Hepatitis B Dose 2 Month/Year Dose 3 Month/Year Dose 4 Month/Year Dose 5 Month/Year Most Recent Dose Month/Year Hepatitis A Varicella (chicken pox) Meningococcal meningitis (MCV4) Had chicken pox Date: Tuberculosis (TB) test Date: Negative Positive If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized. Signature of Custodial Relationship Parent/Guardian: Date: to Camper: Medication: This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp: Medication is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. Name of medication Date started Reason for taking it When it is given Amount or dose given How it is given Breakfast Lunch Dinner Bedtime Other time: Breakfast Lunch Dinner Bedtime Other time: Breakfast Lunch Dinner Bedtime Other time: Breakfast Lunch Dinner Bedtime Other time: The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Cross out those the camper should not be given. Acetaminophen (Tylenol) Phenylephrine decongestant (Sudafed PE) Antihistamine/allergy medicine Diphenhydramine antihistamine/allergy medicine (Benadryl) Sore throat spray Lice shampoo or cream (Nix or Elimite) Calamine lotion Laxatives for constipation (Ex-Lax) Ibuprofen (Advil, Motrin) Pseudoephedrine decongestant (Sudafed) Guaifenesin cough syrup (Robitussin) Dextromethorphan cough syrup (Robitussin DM) Generic cough drops Antibiotic cream Aloe Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Copyright 2014 by American Camping Association, Inc. Page 2/4 Rev.1/2014 LEE/EAW

11 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: General Health History: Check Yes or No for each statement. Explain Yes answers below. Has/does the camper: 1. Ever been hospitalized?... Yes No 11. Had fainting or dizziness?... Yes No 2. Ever had surgery? Yes No 12. Passed out/had chest pain during exercise?.... Yes No 3. Have recurrent/chronic illnesses? Yes No 13. Had mononucleosis ( mono ) during the past 12 months?... Yes No 4. Had a recent infectious disease? Yes No 14. If female, have problems with periods/menstruation?.... Yes No 5. Had a recent injury? Yes No 15. Have problems with falling asleep/sleepwalking?... Yes No 6. Had asthma/wheezing/shortness of breath?... Yes No 16. Ever had back/joint problems? Yes No 7. Have diabetes? Yes No 17. Have a history of bedwetting?.... Yes No 8. Had seizures?... Yes No 18. Have problems with diarrhea/constipation?... Yes No 9. Had headaches?... Yes No 19. Have any skin problems?... Yes No 10. Wear glasses, contacts, or protective eyewear? Yes No 20. Traveled outside the country in the past 9 months?... Yes No Please explain Yes answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. Mental, Emotional, and Social Health: Check Yes or No for each statement. Has the camper: 1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)?... Yes No 2. Ever been treated for emotional or behavioral difficulties or an eating disorder?... Yes No 3. During the past 12 months, seen a professional to address mental/emotional health concerns?.... Yes No 4. Had a significant life event that continues to affect the camper s life?... Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain Yes answers in the space below, noting the number of the questions. The camp may contact you for additional information. Health-Care Providers: Name of camper s primary doctor(s): Name of dentist(s): Name of orthodontist(s): Phone: ( ) Phone: ( ) Phone: ( ) What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper s health that you think important or that may affect the camper s ability to fully participate in the camp program. Attach additional information if needed. Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records. Copyright 2014 by American Summer Camping Application Association, Inc. Page 3/4 Rev.1/2014 LEE/EAW

12 CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Camper Name: First Middle Last Birth Date: Individual Health Record (For Camp Use Only) Initial Screening Date/Time: Initials: Screening has been conducted according to camp protocol and significant findings noted as follows: A. Any signs/symptoms of illness or injury upon arrival?... No Yes as noted below B. History of exposure to communicable disease?... No Yes as noted below C. Additions or corrections to information on this health history?... No Yes as noted below D. Medication given to health-care staff?... No Yes as noted below E. Any signs/symptoms of head lice?... No Yes as noted below Provider notes: (date/time/initial all entries) Exit Note: Check one of the following: Left camp this day with no reported illness or injury symptoms. Left camp this day with the following problem/concern: This person was told about the problem and instructed about follow-up as noted above: Date/Time: Initials: Copyright 2014 by American Camping Association, Inc. Page 4/4 Rev.1/2014 LEE/EAW

13 Recommendations for Licensed Medical Personnel FORM 2 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses Mail this form to the address below by (date) The following non-prescription medications are commonly stocked in camp Health Centers and are used on an as needed basis to manage illness and injury. Medical personnel: Cross out those items the camper should not be given. Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Phenylephrine (Sudafed PE) Pseudoephedrine (Sudafed) Chlorpheneramine maleate Guaifenesin Dextromethorphan Diphenhydramine (Benadryl) Generic cough drops Chloraseptic (Sore throat spray) Lice shampoo or scabies cream (Nix or Elimite) Calamine lotion Bismuth subsalicylate (Pepto-Bismol) Laxatives for constipation (Ex-Lax) Hydrocortisone 1% cream Topical antibiotic cream Calamine lotion Aloe Diet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions:(describe below) The camper is undergoing treatment at this time for the following conditions: (describe below) None. Medication: No daily medications. Will take the following prescribed medication(s) while at camp: (name, dose, frequency describe below) Other treatments/therapies to be continued at camp: (describe below) None needed. Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes If you answered Yes to the question above, what do you recommend? (describe below attach additional information if needed) I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper s parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above.) Name of licensed provider (please print): Signature: Title: Office Address Street City State Zip Code Telephone: ( ) Copyright 2014 by American Camping Association, To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child s health-care provider for review. Dates will attend camp: from to Camper Name: First Middle Last Male Female Birth Date Age on arrival at camp Camper home address: City State Zip Code Custodial parent(s)/guardian(s) phone: ( ) ( ) Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel. Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete all remaining sections of this form (FORM 2). Attach additional information if needed. Physical exam done today: Yes No (If No, date of last physical: ) ACA accreditation standards specify physical exam within the last 12 months. Date: Weight: lbs Height: ft in Blood Pressure / Allergies: No Known Allergies To foods (list): To medications: (list): To the environment (insect stings, hay fever, etc. list): Other allergies: (list): Describe previous reactions: Inc. Rev. 1/14 LEE/EAW First Middle Last Camper Name (For Camp Use) Cabin or Group (For Camp Use) Session Code(s):

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