2017 Camp Requirements. Why does Mercy Street go to camp?

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1 Summer Camp 2017 August 6-11 Once again, Mercy Street is blessed beyond measure in our partnership with Pine Cove Christian Camps! We are excited to be going to Pine Cove Outback located in Columbus, Texas from Sunday, August 6 to Friday, August 11. Heights IS allowing scholars to attend and miss their first four days of school. The total cost per student is $ Application is due LAST DAY OF SCHOOL Below you will find steps to ensure that your child (Mercy Street mentored/active student or Super Thursday student in 4 th -8 th grade) is signed up for camp and that camp will be a wonderful week! Thank you for entrusting your child with us; it is an honor that we are thankful for! 2017 Camp Requirements June 2 nd - Applications Due (attached) with $30 application fee. The $30 will hold a spot for your child. Mentor Coordinators have final attendee discretion. If a student is not accepted to camp Mentor Coordinators will let the student know by July 1 and the $30 will be refunded. Why does Mercy Street go to camp? Mercy Street seeks to step away from the noise of the city and to ask God to use this one week away to impact kids in West Dallas. It is an experience in which Mercy Street staff and mentors draw upon for years to come, walking out with students the new life that Christ has brought about at camp. Camp is a privilege for the student who has demonstrated the ability to control themselves at Mercy Street, school, and in the neighborhood. Work Days Each camp attendee must participate in 1 workday and complete a 6-8 sentence paragraph. Another acceptable option is the creation of a "workday" where mentor and mentee join together in service, letting your mentor coordinator know of the completion of a workday. Behavior - There are behavioral expectations (attached in application) that all campers must obey before applying, during the application process and while at camp. If a child has a difficult time living up to the expectations at any point in the months leading up to camp, they may not receive the opportunity to attend or may be asked to leave camp. Ask any previous camper; they'll tell you that there are tons of great things to do at camp like horseback riding, zip lines, rock climbing, swimming, canoeing, and so much more. You won t want to miss this opportunity! Spots are first come, first serve - applications & $30 are due to your mentor coordinator by the last day of school, June 1 st! 1

2 CAMP WORK DAY Need to attend ONE FRIDAY IN JUNE and complete last page. JUNE 16, 23, & 30 AT MERCY STREET 12pm-4pm Wear tennis shoes and work clothes. No food is provided. We will be riding in vans and helping out at the North Texas Food Bank. 2

3 PINE COVE OUTBACK AND MERCY STREET 2017 Camp Expectations Parents Please Read: We are excited that you are interested in sending your child to Pine Cove camp with Mercy Street this summer. We are thankful that we have this opportunity and believe that it will be a week that will change their life. However camp is not a right, it is a privilege to attend, and there are guidelines so that all the kids will have a safe and enjoyable experience. Fighting and disrespecting others is not tolerated at camp, so if a child is displaying this kind of continuous behavior prior to applying or during the application process they will not be allowed to attend. Camp is open for kids who just completed their 4 th, 5 th, 6 th, 7 th and 8 th grade year of school and participate in the Mercy Street program. Applications are due by the last day of school along with a $30.00 deposit. At the time the application is received it will be reviewed and you will be notified by July 1 as to whether or not your child has been accepted to attend camp. If your child is not accepted the $30.00 deposit will be returned. If your child is accepted they will need to attend 1 work day over the summer. Here are our general expectations: 1. We only use encouraging language. This means cussing, scoring, and insulting are not allowed. 2. We respect everyone at camp. This means no one is to be treated unkindly. 3. We listen and follow instructions of adults. This means when an adult tells you to do something you will do it immediately. 4. We clean up after ourselves. This means at dinner, in the cabin, during all the activities you are expected to clean up your mess. 5. We stay with our group. There is no wandering off. You must be with the group at all times, unless you have permission from an adult to be somewhere else. 6. When it is time to rest, it is time to rest. This means that when someone tells you it is time to go to bed you will go to bed. No questions asked. CONSEQUENCES 1. Green Zone - Warning 2. Blue Zone Time Out Time away from activity, talk with counselor 3. Red Zone Loss of Activity, free time or meal, talk with counselor 4. Fire Zone Time with head counselor (Mercy Street Staff) continued disobedience will result in removal from camp. By signing this document, you acknowledge these expectations and understand the consequences. You understand that continued disobedience will result in removal from camp. CAMPER NAME(S): DATE: CAMPERS SIGNATURE(S): DATE: PARENT(S)/GUARDIAN(S) SIGNATURE(S): DATE: 3

4 PINE COVE OUTBACK AND MERCY STREET 2017 CAMPER PROFILE(Please FULLY complete) Please return this form to a Mercy Street staff by the last day of school. Name of Camper: Name They Go By: Male Female Age (at camp): Grade (THIS school year): Birthday: Parent(s)/Guardian Name: Religious Preference: While at camp, your child will be in a group with several other campers of similar age. They will be supervised by a well trained, college-age counselor who has been selected for his or her maturity, integrity, sensitivity, and spiritual commitment to Jesus Christ. Your cooperation in completing this form will help your child s counselor prepare to provide the needed encouragement and opportunities to make this camping experience easy meaningful and productive as possible. Yes No Will camper have a birthday while at camp? Birth Date: Has your camper been to camp before? When? If not, has your camper ever been away from home alone for two or more days? Are both parents living? Camper lives with? Both parents/ father/ mother/ grandparent/ other Brothers or Sisters? Number older? Number younger? CHECK ALL THAT APPLY: Comfortable in large groups Makes friends easily Needs firm boundaries Prefers small groups Hesitant when meeting new people Responds well to authority Leader Active Adapts well to new situations Follower Reserved Does your child have a mentor with Mercy Street? What is his/her name and please tell us about their relationship? What is your camper most interested in? What activities is your camper involved in? What do you desire your camper to gain from camp? How can we help your child in the area of spiritual growth? Is there anything else we need to know about your camper? (Please be very detailed.) Does your child have any issues with anger or authority? In the past year has your child ever been suspended from school? If yes, please explain the circumstances and the number of times And/Or has your child ever been in trouble with the police? If yes, please explain 4

5 PINE COVE OUTBACK AND MERCY STREET 2016 RELEASE AND CAMPER COVENANT AGREEMENT Dear Parents and Guardians, We at Pine Cove, Inc. ( Pine Cove ) want to inform you of our safety precautions at camp. We feel that we have hired competent and knowledgeable staff. Nonetheless, your camper will be required by our staff to wear safety equipment for any activities requiring protective gear. Even with safety equipment, we at Pine Cove want you to realize that any outdoor camping and recreational activity has inherent dangers that no amount of care, caution, instruction or expertise can eliminate. I hereby affirm that I have been advised of and understand the risks of camping and recreational activities at Pine Cove and that such activities involve dangers and risks and I accept those dangers and risks knowingly and willingly for my camper. I understand that pictures and videos, and audio recordings are taken at camp. I hereby give permission for the use of such pictures, videos, and audio recordings of my camper for the promotion of Pine Cove. In addition, I give permission for my camper to be transported in vehicles for camp approved transportation and activities at Pine Cove and other locations. I understand that the terms herein are contractual and binding and not mere recitals. In signing this document, I hereby certify that I give permission for my camper to participate in the camping and recreational program of Pine Cove. I understand that the terms herein and my agreement to them applies for all of the calendar year of 2017 and all events occurring in I have signed this document as my own free act and in consideration of the agreement by Pine Cove to accept my camper for BY EXECUTION OF THIS DOCUMENT, I KNOWINGLY AND WILLINGLY RELEASE PINE COVE, THE STAFF, THE BOARD OF DIRECTORS, AND ALL OTHERS ACTING FOR OR ON BEHALF OF PINE COVE FROM ALL LIABILITY WHATSOEVER, FOR PERSONAL INJURY, OR INJURIES TO PROPERTY, REAL OR PERSONAL, CAUSED BY, OR ARISING OUT OF CAMPING AND OTHER ACTIVITIES SPONSORED BY PINE COVE. PRINT CAMPER NAME (REQUIRED) FIRST NAME: LAST NAME: PARENT(S)/GUARDIAN(S) SIGNATURE(S): DATE: PARENT(S)/GUARDIAN(S) NAMES PRINTED: 5

6 PINE COVE OUTBACK AND MERCY STREET CAMPER HEALTH FORM Name of group your camper is coming with to Pine Cove: MERCY STREET The purpose of this health form is to assist Pine Cove Health Care Staff in identifying appropriate care. The information in this form will only be available to staff who will be working with your camper. This health form is required for camp attendance and must be completed by the camper s parent/guardian. CAMPER INFORMATION PLEASE PRINT First Name Middle Name Last Name Parent/Guardians Name Parent/Guardians Address Home Phone Cell Phone Work Phone Home Address City ST Zip Date of Birth Male Female Ethnic Background Black White Hispanic Other: Are both parents living? Yes No Camper lives with: Both Parents Father Mother Other PHYSICIAN INFORMATION Name Phone MEDICAID/INSURANCE INFORMATION Member Name Date issued Member ID Issuer ID EMERGENCY CONTACT INFORMATION If Parent/Guardian is not available, please list two Emergency contacts: Emergency contact #1 First Name Last Name Relationship Home Phone Cell Phone Work Phone Emergency contact #2 First Name Last Name Relationship Home Phone Cell Phone Work Phone IMMUNIZATIONS: When did your child last receive a tetanus booster shot? (month and year) Weight: ALLERGIES: WE ARE NOT PEANUT FREE. This camper has NO known allergies This camper has the following allergies: (Please list all allergies and provide information about reaction and treatment.) Medication: Food : Other: (include plant, animal, etc.) 6

7 MEDICAL CONCERNS This camper has NO long term health concerns and is capable of full participation in the camp programs at Pine Cove Camps. Does your child have any of the following? (Check all that apply.) Asthma (even if inhaler is only used occasionally) Convulsions or Seizures (give date of last seizure) Frequent ear infections Hemophilia (Emergent bleeding disorder) Migraine Headaches Active Blood Disorder (HIV, Cancer, Immunosuppressive Disease) Severe allergic reactions Pregnancy (if yes, camper ineligible to attend camp) Anorexia, Bulimia (eating disorders) Diabetes (if yes, please call the Pine Cove Nurse at (903) ) Sickle Cell Anemia (Has the Disease) If yes, camper ineligible to attend camp Bed Wetting Any other illnesses such as Crohn s Disease, Anemias, Seizures, Tourett s etc. If you marked any of the above, please list provide information about supportive health care. Also explain any other illness, surgeries, or injuries requiring an ER visit or hospitalization. Include date of illness/injury and any treatment required: MEDICATION Please list ALL prescription medication, over-the-counter and non-prescription drugs taken routinely. Fill in the blanks completely. Bring enough medication to last all week. Empty bottles will be returned to your camper. ALL DRUGS MUST REMAIN IN THE ORIGINAL CONTAINER. ALL PRESCRIPTION MEDICATIONS MUST BE IN A PHARMACY-LABLED CONTAINER WITH THE CAMPER S NAME ON IT. LOOSE PILLS AND SAMPLES WILL NOT BE ACCEPTED. This camper does NOT take any medications on a regular basis. This camper takes routine medication as follows: (Use a separate sheet if necessary.) Choose Only 1 Column Drug Name Dose Taken Must be given at: Only given at Campers Request: Reason taken for each: Special Instructions: Please list any additional information that would help our medical staff when caring for your camper. 7

8 PARENT/GUARDIAN AUTHORIZATION The information given in this form is complete and accurate to the best of my knowledge. I hereby give my permission for my camper to participate in all camp activities. 1. I hereby give my permission for Pine Cove to use or disclose Protected Health Information (PHI) to necessary staff and any volunteer or paid health care professional or facility for diagnosis, treatment, health care needs, emergency medical care or coverage information for my camper as described on the enclosed Notice of Privacy Practices from Pine Cove, Inc. 2. I hereby give my permission to licensed Pine Cove medical/nursing staff, volunteer physicians and volunteer licensed medical/nursing staff to administer prescribed medication, provide health care, and seek emergency medical care. I hereby give my permission to Pine Cove to provide or seek transportation to medical facilitates for my camper. In case of emergency where I can t be contacted, I hereby give permission to the physician selected by Pine Cove to secure and administer proper treatment, hospitalize, order injections, order anesthesia and/or surgery for my camper. 3. I HEREBY GIVE MY PERSMISSION FOR LICENSED PINE COVE MEDICAL/NURSING STAFF TO ADMINISTER OVER-THE-COUNTER MEDICATIONS TO MY CAMPER AS NEEDED. 4. I understand that the Nurse Manager and/or the Camp Director reserves the right to send home a camper whose medical condition becomes unmanageable and/or places the camper or Pine Cove at risk in the Camp environment. 5. Camping standards DO require that each camper have a physical exam by a Physician, Nurse Practioner, or Physician s Assistant within 24 months (2 years) of attending camp (i.e. campers who will attend August 2017 must have a physical exam between September 2015 and August 2017). I, the parent/guardian of this camper hereby certify that he/she has met the requirement of a physical exam conducted by a Physician, Nurse Practioner, or Physician s Assistant within 24 months (2 years) of attending summer camp in 2017 OR will complete this requirement prior to his/her attendance at Pine Cove. I understand this stipulation is a requirement of Pine Cove and is not optional. My camper has had a physical exam with 24 months of his/her attendance at Pine Cove OR will have one prior to participation for the summer of THIS PHYSICAL EXAM IS REQUIRED FOR ATTENDANCE. 6. I agree to make Pine Cove aware of all known medical issues regarding my camper s health and will update this form with additional issues that may occur between now and the start of camp. 7. I agree and understand that Pine Cove s Supplemental Camper Insurance is a limited offering. The maximum amount is $2,500 for accidents and $750 for illness. My insurance information will be provided for amounts that exceed this offering. PARENT/GUARDIAN SIGNATURE REQUIRED: DATE: 8

9 Camper, not parent/guardian, with your best effort, in 6-8 sentences write about one of the following topics (below) You must complete and turn in your sentences with your application, $30 and complete a 4 hour work day to attend Pine Cove this summer. Topic 1: In 6-8 sentences, explain why you would like to attend Pine Cove this summer? (It's okay if you have never been before! You can still tell us WHY you'd like to go!) Topic 2: In 6-8 sentences explain why you love Pine Cove, describe in detail all the things you love about Pine Cove! Topic 3: In 6-8 sentences Tell us how Pine Cove has impacted your life, and what you have learned from your time at Pine Cove. Camper Name: Grade: 9