CHRISTIAN CAMP CHILDREN S HEARTS CAMP RULES AND REGULATIONS FORM

Transcription

1 CHRISTIAN CAMP CHILDREN S HEARTS CAMP RULES AND REGULATIONS FORM REGISTRATION Hello parents and friends of the Christian Camp Children s Hearts. We have begun registration for this year s summer camp. We are accepting all children who will be going into1 st grade through 9 th grade in September 2017 (essentially elementary and middle school children). As space is limited and it is of utmost importance that we know approximately how many children to plan for, we request that you provide a speedy answer. Please read and complete this entire application and return it (in person or by ) to either Dmitriy Makarevich or Oleg Makarevich. You are also welcome to send in your applications and payments to either Dmitriy or Oleg at the following address; also provided are their addresses and phone numbers in case of any questions/concerns: 6964 Copperbend Ln Baltimore, MD Dmitriy Makarevich Oleg Makarevich dmitriymak@yahoo.com olegmakarevich7@gmail.com CAMP ADDRESS We encourage you to send as much mail as you like during the week of camp! Every camper looks forward to receiving mail. Parents should not send mail after Tuesday of that week (it will not arrive before the end of camp). All mail should be sent to: Indian Lake Christian Camp Attention: Camper's Name/ Slavic Church Week 3915 River Road Darlington, MD ARRIVAL and DISMISSAL DATES: July 30- August 4, 2017 CAMP DEAN: Katerina Petruk Registration will begin at 3 PM on SUNDAY JULY 30, Registration closes at 5 PM on SUNDAY so be sure to call the camp director if you cannot come to camp by that time. The camp dean's phone number is Alternative phone number is Make sure you tell us what time we can expect you if you are coming late. Otherwise, your child's bunk may be given to another camper, even if you have already pre-registered and/ or prepaid. The program will end on FRIDAY AUGUST 04, 2017 at 5 PM. Parents are asked to arrive at camp at 4:30 PM at the earliest. Until that time, campers will be involved in closing programs. VISITS TO THE CAMP Visits to the camp by parents or others are strongly discouraged during any camp session. We request that campers receive NO phone calls or visits during camp. Such actions disrupt the camp program and promote homesickness among younger campers. Parents will be notified immediately if any emergency occurs. Visitors must report to the camp director upon arrival. No visitors will be permitted to disrupt the camp schedule. The camp s dean phone number is Alternative phone number phone is

2 WHAT YOU SHOULD BRING TO THECAMP Overnight campers should bring Bible, pencil or pen, notebook and flashlight, toothbrush, toothpaste, soap, shampoo, and any other toiletries you may need. Towels and washcloths, plenty of casual and recreation clothing (modesty is expected for both boys and girls), including warm clothes and a jacket. Clean clothing for evening services. Tennis shoes plus shoes to wear to bathhouse and pool (the campground can be rough in places, so bring appropriate shoes). Recreational equipment (such as a ball glove or bat); camera, sleeping bag or bedding for a single bed plus a pillow and blanket (it can get cold at night!). Swimsuit (one-piece for girls; a dark t-shirt may be worn over a two-piece swimsuit; modesty is expected for girls and boys). WHAT YOU SHOULD NOT BRING TO CAMP Knives, firearms, comic books, radios, tapes or CD players, I-pods, electronic games, any type of tobacco products, alcohol or drugs. ALL CELL PHONES ARE TO BE LEFT HOME! All of these items found in possession of the camper will be confiscated and held by the director of the camp. CAMP RULES 1) All campers, staff, and visitors are expected to follow the schedule unless they have the camp director s permission to do otherwise. 2) No one is to leave the camp at any time without permission from the camp director. 3) Cars brought by campers will be parked and locked for the week and the keys turned over to the camp director until the close of camp. 4) No one is to be in possession of any of the forbidden items listed above. 5) Campers and staff must wear enclosed shoes during daily activities. 6) Flip-flops can be worn to and from the bathhouse and approved activities. 7) All illnesses and/or injuries must be reported immediately to the camp nurse. CAMP PHOTO A group photograph will be available for each camper free of charge. Photos will be given the last day of camp during sign out. The parent must sign the camper out in order to receive the photo. COST $60 for children of Slavic Church of Christ members $250 for all other children PAY BY CHECK or CASH: make checks payable to "SLAVIC CHURCH OF CHRIST" REFUND POLICY There will be no refunds for cancellations less than 10 days before camp starts. There will be no refunds if a camper goes home homesick or ill There will be a $25 charge for any checks returned for insufficient funds. You MUST have the following forms completely filled out prior your child can start the camp: - AUTHORIZATION FOR TREATMENT OF MINORS AND IN CASE OF HOSPITAL EMERGENCY - CAMPER MEDICAL PROTOCOL FORM - MEDICATION ADMINISTRATION AUTHORIZATION FORM (For any medications that are not listed on the Camper Medical Protocol Form _ - CAMP SIGN-OUT FORM - PARTICIPANT RELEASE of LIABILITY, WAIVER, and INDEMNITY AGREEMENT - A COPY OF HEALTH INSURANCE CARD

3 AUTHORIZATION FOR TREATMENT OF MINORS AND IN CASE OF HOSPITAL EMERGENCY CAMPER S NAME: AGE BIRTHDATE: GRADE LEVEL NEXT FALL GENDER ADDRESS OF CAMPER (street) (city) (state) (zip code) Mother/Father or Legal Guardian (Please Print): EMERGENCY PHONE NUMBERS WHERE YOU CAN BE REACHED AT ANY TIME YOUR CHILD IS IN CAMP: (H) (W) (C) CAMPER S PEDIATRICIAN and OFFICE PHONE NUMBER: CAMPER S DENTIST and OFFICE PHONE NUMBER: Does Camper have any allergies? Medicine? Food? Pollen? Other? 2. Is Camper allergic to bee sting? How Severe? 3. Has Camper had surgery in the last year? If yes, explain 4. Has Camper had serious Illness in the last year? If yes, explain 5. Has Camper had medical care within last 3 months? If yes, explain 6. When did Camper have last tetanus shot? Month Year 7. Does Camper have any chronic medical problems? If yes, what? 8. Is Camper subject to seizures? Fainting? Headaches? 9. Is Camper subject to sleepwalking? Bedwetting? 10. Does Camper have any dietary restrictions? If yes, explain 11. Is there any reason why Camper should not participate in all recreational activities? 12. Is there any behavioral or psychological issue with your Camper that our staff should be aware of? Are any medications being sent with Camper? List: If medication(s) is being sent with Camper please be certain that MEDICATION ADMINISTRATION AUTHORIZATION FORM is completed and medication(s) is given to Camp Nurse with written instructions upon arrival at registration time. All medications must be in pharmacy or manufacturer s bottles/containers [turn over]

4 CAMPER IMMUNIZATION INFORMATION For campers who reside within the United States, a United States territory or the District of Columbia: - State/territory in which CAMPER resides: - Is CAMPER exempt from any immunizations: - If YES, list them: For campers who reside outside the United States, A United States territory, or the District of Columbia: - Country in which child resides: - Attach Department form DHMH-896 (record of vaccination or immunity) Please initial each statement: I, the undersigned, do grant permission that my child be treated for minor illnesses/injures as it is outlined in the CAMPER MEDICAL PROTOCOL FORM by the Camp Nurse or his/her designated agent, should the treatment deemed necessary. I, the undersigned, do authorize a hospital to render medical service to my son/daughter when it is medically necessary, during our absence. I, the undersigned, do for myself, my heirs, personal representatives, and assignees waive and release any and all rights and claims for damages against staff of the CHRISTIAN CAMP CHILDREN S HEARTS for any and all injuries which may be suffered by my son/daughter, or self (named herein) while attending the CHRISTIAN CAMP. Permission is also granted for Camp Director or Nurse or his/her designated agent to take my child to a doctor or hospital to be treated in case of sickness or any emergency. Permission is also granted for a hospital to release medical records to the camp and/or health insurance company for insurance purposes. I, the undersigned, give permission for pictures taken at camp of the campers to be used for publicity purposes in the future including being posted on the SLAVIC CHURCH OF CHRIST or INDIAN LAKE CHRISTIAN CAMP website and Facebook. I, the undersigned, have read the CAMP RULES AND REGULATIONS FORM and have discussed all listed rules and regulations with the camper for whom these registration forms are being prepared. I understand the DEAN will review these rules at the beginning of the week. Any violation by CAMPER may result in expulsion from the camp and forfeiture of fees. Parent/Legal Guardian Signature: Parent/Legal Guardian (Print Name): Date:

5 CAMP SIGN-OUT FORM In order to better insure the safety of our campers, we have initiated this sign-out form for each child. Please fill out all the information below and bring with you on registration day. Be certain that anyone who plans to pick up your child at any time during the week and/or at the end of the week realize that he/she must sign out your child with the camp director or his designated agent by signing this form below. CAMPER S NAME: ADDRESS OF CAMPER (street) (city) (state) (zip code) Name of person who will be picking up camper List any person(s) who do NOT have authority to pick up the camper: Do you expect this camper to be picked up BEFORE the close of camp? Yes No IF YES, list the date & time of early pick-up and return (if returning before camp ends) as well as the person (s) authorized to make pick-up: PICK-UP: Date Time RETURN: Date Time Name of person who will be picking up camper: AUTHORIZED PERSON MUST SIGN BELOW WHEN PICKING UP CAMPER EARLY dismissal: Date: Time: REGULAR dismissal: Date: Time: I understand that no camper may leave the camp grounds until either the camp director or his/her designated agent is notified and gives permission for dismissal Parent/Legal Guardian Signature: Parent/Legal Guardian (Print Name) Date:

6 CAMPER MEDICAL PROTOCOL FORM CAMPER S NAME: Camper s allergies: Please circle what can be given to your child: *For headache, menstrual discomfort or general discomfort: Tylenol Ibuprofen *For stomach complaints: Mylanta Maalox Pepto Bismol Tums/ Antacids *For minor cuts and abrasions: Wash with soap and water, apply Neosporin and cover with band aid/gauze & tape *For allergy, bug bites, or bee sting: Benadryl Sting Stick *For severe allergic reaction: Epipen use authorized *For rash, poison ivy, poison oak or mosquito bites: 1% hydrocortisone cream Calamine lotion Caladryl lotion *For throat Irritation and/or cough Cough drops Throat lozenges Cough syrup *Sunscreen application Yes No *Bug spray application Yes No *For eye irritation Sterile saline Visine *For tick bite will remove tick, tape to paper, clean affected area, recheck daily, notify parent if redness occurs before pick up. Otherwise, we will give the tick paper to parents upon dismissal. Parent/Legal Guardian Signature: Parent/Legal Guardian (Print Name) Date:

7 CHRISTIAN SERVICE CAMP Participant Release of Liability, Waiver and Indemnify Agreement This form MUST be signed with NO additions, deletions or changes for the participant to take part in the Indian Lake Christian Service Camp Giant Swing and/or Zipline Adventure course activities. (llcsca) Participant's Name: Age Address: Phone: Health Questions: Do you have any health problems or disability that may affect your ability to participate in the ILCSC Adventure program? If yes, please explain Emergency contact Phone Please list all allergies (if any) and reactions or medications you may be taking The activity you have signed up for involves physically and emotionally demanding activities in an outdoor setting. It includes climbing, jumping and other rigorous activities on natural and man-made structures that are on the ground or at low, medium or high distance from the ground. You will be working with certified ILCSC facilitators and staff along with others in your group. It is possible that you may be injured while participating in the program either because of your own conduct, conduct of others in your group, conduct of ILCSC facilitators or staff, or the condition of the premises. We want to make sure you understand the risks of injury before you decide to participate in the program. It is required that you read the following information very carefully, understand it and sign it before you begin. I AM FULLY AWARE THAT THE ILCSCA PROGRAM THAT I AM CHOOSING TO PARTICIPATE IN INCLUDES RIGOROUS PHYSICAL ACTIVITIES. I AM ALSO AWARE THAT THERE ARE RISKS OF PHYSICAL INJURY OR HARM FROM PARTICIPATING IN THE ILCSCA PROGRAM. I VOLUNTARILY ELECT TO PARTICIPATE IN THE PROGRAM ANDTO ASSUME THE RISKS OF INJURY OR HARM THAT COULD RESULT FROM PARTICIPATION ON MY BEHALF OR ON BEHALF OF MY PERSONALREPRESENTITIVES AND HEIRS. I HEARBY RELEASE ILCSC AND ITS OFFICERS, EMPLOYEES, AGENTSAND DIRECTORS FOR ALL LIABILITY FOR ANY INJURY OR HARM TO ME FROM PARTICIPATING IN THE ILCSCA PROGRAM. WHETHER THE INJURY OR HARM IS CAUSED BY THE NEGLIGENCEOF ILCSC OR OTHERWISE I HAVE READ AND UNDERSTAND THIS RELEASE LIABILITY. I VOLUNTARILY SIGN AND HEREBY GIVE PERMISSION FOR ILCSC TO ADMINISTER BASIC FIRST AID OR TO SEEK APPROPIRATE MEDICAL ASSISTANCE FOR THE PARTICIPANT LISTED ABOVE. I am aware that the releases require strict adherence to its standards of safety and conduct. I agree to fully abide by these standards or to accept dismissal for refusing to adhere to them. I hereby grant the releases to take and use photographs, video, film and other images of me participating in or observing the activities. I waive my right of privacy, publicity, compensation, copyright or other rights to those images and I consent to the releases using those images for any purposes. This release shall be binding to the fullest extent permitted by law. If any provision of this release is found to be unenforceable, the remaining terms shall be enforceable. Signature of Adult Participant Date FOR PARTICIPANTS OF MINORITY AGE: This is to certify that I, as Parent, Guardian, Temporary Guardian with legal responsibility for this participant, do consent and agree not only to his/her release of all releases, but also to release and indemnify the Releasees from any and all liabilities incident to his/her involvement in these activities and programs for myself, my heirs, assigns, and next of kin. Date Signature of parent or legal guardian if participant is a Minor, and by their signature, they on my behalf release all claims both they and I have. *ILCSC - Indian Lake Christian Service Camp *ILCSCA - Indian Lake Christian Service Camp Adventure

8 MEDICATION ADMINISTRATION Department of Health & Mental Hygiene (DHMH) AUTHORIZATION FORM Center for Healthy Homes and Community Services (CHHCS) for Youth Camps in Maryland (410) Toll free MD-DHMH ext This form must be completed fully in order for youth camp operators and staff members to administer the required medication or for the camper to self administer medication. A new medication administration form must be completed at the beginning of each camp season, for each medication, and each time there is a change in dosage or time of administration of a medication. Prescription medication must be in a container labeled by the pharmacist or prescriber. Nonprescription medication must be in the original container with the instructions for use. Nonprescription medication includes vitamins, homeopathic, and herbal medicines. An adult must bring the medication to the camp and give the medication to an adult staff member. I. PRESCRIBER S AUTHORIZATION 1. CHILD S NAME 2. DATE OF BIRTH / / Month Day Year 3. CONDITION FOR WHICH MEDICATION IS BEING ADMINISTERED: 4. EMERGENCY MEDICATION [ ] YES -If yes, see Section III below. [ ] NO 5. MEDICATION NAME 6. DOSE 7. ROUTE 8. TIME/FREQUENCY OF ADMINISTRATION 9. IF PRN, FREQUENCY 10. IF PRN, FOR WHAT SYMPTOMS 11. KNOWN SIDE EFFECTS SPECIFIC TO CHILD 12. MEDICATION SHALL BE ADMINISTERED during the year in which this form is dated in 14b below unless more restrictive dates are specified in 12a and 12b. This authorization is NOT TO EXCEED 1 YEAR. 12a. FROM / / Month Day Year 12b. TO / / Month Day Year 13. PRESCRIBER S NAME/TITLE This space may be used for the Prescriber s Address Stamp TELEPHONE FAX ADDRESS CITY STATE ZIPCODE 14a. PRESCRIBER S SIGNATURE (Parent/guardian cannot sign here) (ORIGINAL SIGNATURE OR SIGNATURE STAMP ONLY) II. PARENT/GUARDIAN AUTHORIZATION 14b. DATE I request the authorized youth camp operator/staff to administer the medication or supervise the camper in self administration if authorized as prescribed by the above prescriber. I certify that I have legal authority to consent to medical treatment for the child named above, including the administration of medication at the facility. I understand that at the end of the authorized period, an adult must pick up the medication, otherwise it will be discarded. I authorize camp personnel to communicate with the prescriber as allowed by HIPAA. 15a. PARENT/GUARDIAN SIGNATURE 15b. DATE 15c. HOME PHONE # 15d. CELL PHONE # 15e. WORK PHONE # III. AUTHORIZATION FOR SELF ADMINISTRATION / SELF CARRY (OPTIONAL) This section should only be completed if this medication is approved for self administration. Self carry is only permitted for emergency medications such as inhalers, insulin and epinephrine. Both the prescriber and the parent/guardian must consent to self administration below. However, youth camp operators are not required to permit self administration or self carry. I consent that the child named above is able to self administer the medication listed. I authorize self administration of the above listed medication for the child named above under the supervision of an authorized youth camp operator/staff member. If indicated below, the child named above may self carry emergency medication. 16a. PRESCRIBER S SIGNATURE authorizing self administration 17a. PARENT/GUARDIAN S SIGNATURE authorizing self administration 16b. SELF CARRY EMERGENCY MEDICATION (Check One) [ ] YES [ ] NO [ ] N/A - Not emergency medication 17b. SELF CARRY EMERGENCY MEDICATION (Check One) [ ] YES [ ] NO [ ] N/A - Not emergency medication 16c. DATE 17c. DATE DHMH-4758 (02/16) Page 1 of 1