Peterkin Camp and Conference Center

Transcription

1 Camper Information Peterkin Camp and Conference Center A Ministry of the Episcopal Diocese of West Virginia Summer Camp Registration Please complete one form per camper per camp. Check which camp your camper will attend. Senior Camp (June 21 to 27) Junior Camp (July 19 to July 25) Beginner Camp (July 1 to 4) MAD Camp (July 26 to August 1) Intermediate Camp (July 5 to 11) Camper Name: Male Female Grade in Fall 15: First M.I. Last Camper T-shirt size: of Birth (MM/DD/YY): Age at Camp: Name to go by at Camp: Parent/Guardian with Legal Custody Information Name: Relationship to Camper: Address: Home Phone: Cell Phone: Business Phone: Home Church: Transportation Information We must know in writing who will be transporting your child from camp to home. Only the person authorized by the parent/guardian will be permitted to transport your child home from camp. is authorized to transport from Peterkin to home (Driver s name) (Camper s name) A part of the camp checkout procedure is the verification of the name of the person authorized to transport the camper home. Please notify Peterkin before the close of camp if there is a change from the person named above. Parent/Guardian Signature I, the parent/guardian of, give permission for his/her full participation in events associated with the Peterkin Camp and Conference Center, including but not limited to trail hiking, the river float/canoe trip, and campfire activities. I give permission for my child to travel by church van or private vehicle while at Peterkin Camp and Conference Center. I give my permission for photographs or video footage of my child to be used by The Diocese of West Virginia and Peterkin Camp and Conference Center for promotional purposes (brochures, on diocesan websites, promotional videos, Facebook, YouTube, etc). I give my permission for my child s contact information to be included on a roster and his/her participation in a group photo that will be distributed to other participants. I agree to hold the Diocese of West Virginia, Peterkin Camp and Conference Center, and any associated agencies and persons harmless and waive any claims for payment for accident, injury, disability or damages to the person or property of the aforementioned child arising out of or connected with his/her participation in any activity related to his/her participation in the aforementioned activity. Parent/Guardian Signature

2 Registration Form Camper Name: Camp Attending: The Diocese of West Virginia is devoted to sharing the experience of Peterkin. To that end, the Diocese can provide a scholarship, upon receipt of completed camper registration form and scholarship request, to cover up to one-third of the registration cost of camp. All requests for diocesan scholarships must include the signature of your rector or priest-in-charge. The Diocese asks the camper s home congregation to provide a scholarship to cover one-third of the registration cost. The camper is asked to provide the final one-third. If this scholarship model does not fit your financial situation, please contact the diocesan office to discuss other options. Please also keep in mind that the diocese does subsidize all Peterkin campers by providing significant direct support to Peterkin s operating budget. All scholarship requests and financial issues will be handled with utmost discretion by the Diocesan Office. All inquires should be directed to Mr. David Ramkey, Diocesan CFO at dramkey@wvdiocese. org or All requests for scholarships MUST be made prior to arriving at camp. requests will be accepted after your child s camp starts. If requesting a diocesan scholarship, please state why here and the specific amount requested: All campers receiving scholarships must have their applications signed by their priest. Due to limited funds, we ask clergy to consider the need and merit before signing this request. Clergy Signature Name of Person/Entity Responsible for Payment: Address: Method of payment (check all that apply): Check Visa or Mastercard Scholarship Checks should be made payable to Peterkin Camp and Confernce Center If using Visa or Mastercard: Name on Card: Card Number: _ Expiration: Camp Fee: Amount Enclosed:* 2015 Camp Fees Youth Camps $400 (includes Junior, Intermediate, Senior, M.A.D.) Balance Due at check-in: If applicable, please list scholarship amounts and sources: * A minimum of a $50 deposit is required with each camper registration. This deposit is non- refundable in the event of cancellation. Any remaining balance, including funds from scholarships, is due when your child checks-in on the first day of camp. Beginner Camp $160 Mini Camp Adult $230 Youth $160 Family Camp Adult $425 Youth (under 10 years old) $240 Please mail registration materials and payment to: Peterkin Camp and Conference Center 286 Club House Rd. Romney, WV 26757

3 A Ministry of the Episcopal Diocese of West Virginia An Accredited AmericAn camp AssociAtion camp Camper Name: Male Female Camp Attending: Birth (MM/DD/YY) : Age at Camp: Camper Home Address: Street Address City State Zip Code Parent/guardian with legal custody to be contacted in case of illness or injury: Name: Relationship to Camper: Main Phone: Secondary Phone: Home Address: (If different from above) Street Address City State Zip Code Second Parent/guardian or other emergency contact: Name: Relationship to Camper: Main Phone: Secondary Phone: Additional emergency contact: Name: Relationship to Camper: Main Phone: Secondary Phone: Allergies: 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, the reaction seen and treatments/precautions needed - i.e. Epinephrine.) Diet, Nutrition: This camper eats a regular diet. This camper eats a regular vegetarian diet. This camper has special food needs. (Please describe below.) Restrictions: 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.) Medical Insurance Information: This camper is covered by family medical/hospital insurance Include a copy of your insurance card and, if appropriate, copy both sides of the card. Insurance Company Policy Number Subscriber_ Insurance Company Phone Number Parent/Guardian Authorization for Health Care: 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 : to Camper:

4 Page 2 of 3 Camper Name: Birth (MM/DD/YY) : Immunization History: Immunization Most Recent Dose Month/Year Tetanus booster* (dt) or (TdaP) My camper is fully immunized as required by my local school system or state guidelines. My camper HAS NOT been fully immunized as required by my local school system or state guidelines. 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: : 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. We 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. We can only dispense medicine as documented on the bottle or otherwise by doctor/pharmacist. Name of Medication started Reason for taking it When is it taken Amount or dose given How is it given 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) Ibuprofen (Advil, Motrin) Phenylephrine decongestant (Sudafed PE) Antihistamine/allergy medicine Pseudoephedrine decongestant (Sudafed) Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Sore throat spray Generic cough drops Lice shampoo or cream (Nix or Elimite) Antibiotic cream Calamine lotion Aloe Laxatives for constipation (Ex-Lax) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol) Naproxen (Aleve)

5 Page 3 of 3 Camper Name: Birth (MM/DD/YY) : General Health History: Check or for each statement. Explain answers below. Has/does the camper: 1. Ever been hospitalized? 2. Ever had surgery? 3. Have recurrent/chronic illness? 4. Had a recent infectious disease? 5. Had a recent injury? 6. Had asthma/wheezing/shortness of breath? 7. Have diabetes? 8. Had seizures? 9. Had headaches? 11. Had fainting or dizziness? 12. Passed out/had chest pain during exercise? 13. Had mononucleosis ( mono ) during the past year? 14. If female, have problems with periods/menstruation? 15. Have problems with falling asleep/sleepwalking? 16. Ever had back/joint problems? 17. Have a history of bed-wetting? 18. Have problems with diarrhea/constipation? 19. Have any skin problems? 10. Wear glasses, contacts or protective eye ware? 20. Travelled outside the country in past 9 months? Please explain answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel. Health-Care Providers: Name of camper s primary doctor(s): Phone: Name of dentist(s): Phone: Name of orthodontist(s): Phone: Mental, Emotional, and Social Health: Is there anything that has happened recently in the camper s life that we should know that would impact their time at camp? Is there 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? What Have We Forgotten to Ask?