Provider notes: (date/time/initial all entries)

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Veronica Wiggins
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1 Please staple. Cabin Name/Number Sessin Name C H F Initial Screening Date/Time: Initials: Screening has been cnducted accrding t camp prtcl and significant findings nted as fllws: A. Any signs/symptms f illness r injury upn arrival? N Yes, as nted belw B. Histry f expsure t cmmunicable disease? N Yes, as nted belw C. Additins r crrectins t infrmatin n this health histry? N Yes, as nted belw D. Medicatin given t health-care staff? N Yes, as nted belw E. Any signs/symptms f head lice? (ACA required questin) N Yes, as nted belw Medicines: All medicatins (prescribed r ver the cunter) must be presented in their riginal cntainers/packaging with nted dsages/prescriptin infrmatin (required by law). Prvider ntes: (date/time/initial all entries) (Fr Camp Use Only) Exit Nte: Check ne f the fllwing: Left camp this day with n reprted illness r injury symptms. Left camp this day with the fllwing prblem/cncern: This persn was instructed t fllw-up as nted abve: Date: Initials: _ Page 1

2 Please staple. Cabin Name/Number Sessin Name CAMPER HEALTH RECORD (Fr Camp Use Only) Prvider ntes cntinued: (date/time/initial all entries) Page 2

3 Page 1 Please staple. Office Use Only Cabin Name/Number Sessin Name Cunselrs Ntes _ 2017 Metrplis f Pittsburgh Summer Camp C H R Please read carefully: This cmpleted frm needs t be reviewed/signed by a LICENSED HEALTH CARE PROVIDER. All Camper Health Recrds must be presented at Registratin n the first day f camp. Please bring a hard cpy with yu t camp, and als send a scan ne week befre arrival t <medfrms@pittsburgh.garch.rg>. We will be unable t permit any camper t remain at camp withut a cmpleted Health Recrd. If yur child has a special need r health issue that yu think shuld be addressed befre camp, please cntact the Camp Ministries Crdinatr, r <camp@pittsburgh.garch.rg>. Pages 3-6 are t be cmpleted by the parent/guardian and reviewed by the health care prvider at the time f examinatin. This frm is used t help Camp Medical Staff in determining apprpriate care. This infrmatin will nly be shared n a need t knw basis with Camp Staff. Emergency Cntact Infrmatin Camper Name _ Last First Middle Hme Address Phne Street City State Zip Area Cde/Phne Birth Date Age Gender_ Parent/Guardian Name Hme Address Cell Phne _ Street City State Zip Area Cde/Phne Business Address Phne _ Street City State Zip Area Cde/Phne Other Parent/Guardian Name_ Hme Address Cell Phne Street City State Zip Area Cde/Phne (If different frm abve) Business Address Phne _ If parent and ther parent/guardian are nt available in an emergency, please ntify: Name/Relatinship Phne _ Immunizatin Histry Prvide the mnth and year fr each immunizatin. Starred MUST be current. Cpies frm health-care prviders are acceptable; please attach t this frm. Diptheria, tetanus, pertussis* Tetanus bster* Measles, mumps, rubella* Pli* Haemphilus infleuzae type B _ Area Cde/Phne Area Cde/Phne Street City State Zip Area Cde/Phne Area Cde/Phne Hepatitis B Hepatitis A Varicella (chicken px) _ Menigcccal meningitis Tuberculsis (tb) test If yur child has nt been fully immunized, please sign the fllwing statement: I understand and accept the risks t my child frm nt being fully immunized. Signature f parent/guardian: Date:

4 Name f Family Physician Phne Insurance Infrmatin Des the camper have family medical/hspital insurance? Yes N Carrier _ Name f Plicy Hlder Area Cde/Phne Name f Family Dentist Phne Area Cde/Phne Plicy r Grup # Relatin t Camper SS # f Plicy Hlder r Insurance ID Number A cpy f the Insurance Card must be attached here. A cpy f the Insurance Card must be attached here. Frnt f Card Back f Card Mental, Emtinal and Scial Health Has the camper... (Please answer Yes r N fr each statement): 1. Ever been treated fr attentin deficit disrder (ADD) r attentin deficit/hyperactivity disrder (AD/HD)? 2. Ever been treated fr emtinal r behaviral difficulties r an eating disrder? 3. During the past 12 mnths, seen a prfessinal t address mental/emtinal health cncerns? 4. Had a significant life event that cntinues t affect the camper s life? (Histry f abuse, death f a lved ne, family change, adptin, fster care, new sibling, survived a disaster, etc.) 5. Experienced any ther medical r emtinal cnditin which may require additinal attentin by camp staff? _ Please explain Yes answers in the space belw, nting the number f the questin, use additinal sheets if needed: IMPORTANT PLEASE READ CAREFULLY AND SIGN Custdial Parent r Guardian Cnsent: This health histry is crrect and cmplete t my knwledge. The persn described has permissin t participate in all camp activities except as nted. I hereby give permissin t the camp t btain relevant health care, administer prescribed medicatins, and seek emergency medical treatment, including rdering x-rays r rutine tests. I agree t the release f any recrds necessary fr insurance purpses. I give permissin fr the camp t arrange related transprtatin fr my child. The purpse f nsite camp medical staff is slely fr administering medicatins and perfrming triage and minr first-aid. In the event that I cannt be reached in an emergency, I hereby give permissin t the health care prvider selected by the camp t secure and administer treatment, including hspitalizatin. Parents/guardians are respnsible fr ALL medical bills incurred while at camp (dctr visits, emergency rm visits, and prescriptins). All attempts will be made t cntact parent/guardian befre taking the camper fr ff camp medical care. A descriptin f care received will be given t the parent. Signature f Custdial Parent/Guardian: _ Date: _ Please bring all medicatins t camp in their riginal cntainers (legal requirement) and in a plastic Ziplc bag that is labeled with the Camper s name. Page 2

5 CAMPER HEALTH HISTORY FORM (T be cmpleted by Parent/Guardian) Participant has r has had any f the fllwing: (Please check if YES.) Recent injury, illness, infectin Jint prblems Chrnic illness/cnditin Back prblems Surgery Skin prblems (i.e. rash, acne) Frequent headaches/migraines Mnnuclesis in the last 6 mnths Recent head injury Asthma Heart murmur Diarrhea/cnstipatin Diabetes Sleepwalking Glasses, cntacts Orthdntic appliances Frequent ear infectins Significant emtinal difficulties Passed ut during r after exercise Bed-wetting Dizzy during r after exercise Eating disrder High bld pressure Other Please explain any yes answers: IF FEMALE (Please answer YES r NO.) Has this persn menstruated? _ If nt, has she been tld abut it? _ Is her menstrual histry nrmal? ALLERGIES (List all knwn and describe the reactin and management f the reactin.) Medicatin Allergies List *Fd Allergies List - (Nuts, lactse intlerance, shell fish, etc.) *Medically Diagnsed Gluten Allergy - (Due t the extremely high cst f Gluten-free prducts, there will be a $50.00 additinal camp fee charged by Camp Nazareth fr all wh request a medically diagnsed gluten-free menu. Please nte, Campers are unable t bring their wn meals.) Other Allergies List - (Insect stings, hay fever, asthma, animal, plant, etc.) *Please nte, unless medically diagnsed fd allergies are invlved, n special dietary measures will be taken. If yur child has a specific diet, yu will need t make arrangements prir t camp and prvide fr the necessary dietary changes. Please the Camp Directr at least tw weeks prir t the start f the sessin: camp@pittsburgh.garch.rg NON-PRESCRIPTION MEDICATIONS The fllwing nn-prescriptin medicatins may be given t my child, if needed: (Please answer YES r NO) Tylenl/Acetaminphen Decngestant Advil/Ibuprfen Benadryl Cugh syrup, lzenges, thrat spray External intments, sprays, ltins Antacid Pept Bisml Imdium Other medicatins, per discretin f Camp Medical Staff Page 3

6 MEDICATIONS (T be cntiued at camp) Please keep in riginal bttles labeled with health care prvider s name, phne number, dsage and instructins (legal requirements). Place all medicines in ne plastic Ziplc bag and label with Camper s name. Have available fr cllectin at Registratin. Please list all prescriptin and nn-prescriptin medicatins taken n a regular basis. It is camp plicy that ALL medicatins be kept and secured at the Camp Health Center. This includes vitamins/supplements and medicatins taken n an as needed basis. The nly medicines that may be left in cabins are creams and inhalers. Please attach additinal pages fr mre medicatins. Make sure t ntify the medical staff when yu arrive at camp if additinal medicatins have been added after the health frm was filled ut. 1) Med Dsage Specific times per day Reasn fr taking 2) Med Dsage Specific times per day Reasn fr taking 3) Med Dsage Specific times per day Reasn fr taking 4) Med Dsage Specific times per day Reasn fr taking 5) Med Dsage Specific times per day Reasn fr taking Please nte: If yur child has a special need/health issue that yu think shuld be addressed befre Camp begins, please cntact the Camp Directr: r camp@pittsburgh.garch.rg TO BE COMPLETED BY A LICENSED HEALTH CARE PROVIDER Recmmendatins and Restrictins (Explain what limitatins are necessary.) Dietary (vegetarian, etc.): n restrictin restrictin: Physical Activity: n restrictin restrictin: Swimming/Diving: n restrictin restrictin: Capable f swimming in the deep end f the pl? Yes N uncertain (Certified camp lifeguard may evaluate.) Other restrictins: I examined this individual n (M/Day/Yr) (Exam Date must be perfrmed within 12 mnths f Camp.) BP Weight Height I have persnally reviewed the Camper Health Recrd (Pages 3 6) and have made any necessary crrectins r additins. Signature f Licensed Health Care Prvider Name (printed) Title Address Phne Date Page 4

7 Camper, Parents, and Staff, please make sure that yu review and understand this plicy. Apprval is required fr participatin in the Metrplis f Pittsburgh Yuth & Yung Adult Ministries prgrams. Yu will be asked t agree t this during the Online Registratin prcess, and in the Terms & Cnditins frm t be submitted at Registratin. In general, the Metrplis f Pittsburgh views scial netwrking sites (Facebk, Twitter, Instagram, etc.), persnal websites, and weblgs psitively and respects the rights f campers t use them as a medium f self-expressin. If a camper r member f the staff chses t identify himself r herself as a Participant at the Metrplis f Pittsburgh Camp Prgram n such Internet venues, sme readers f such websites r blgs may view the Participant as a representative r spkespersn f the Metrplis f Pittsburgh. In light f this pssibility, the Metrplis f Pittsburgh requires, as a cnditin f participatin in the camp, that all participants bserve the fllwing guidelines when referring t the Metrplis f Pittsburgh, its prgrams r activities, its campers, and/r ther staff, in a blg r n a website. All participants must be respectful in all cmmunicatins (texts and phts) and blgs related t r referencing the camp, camp staff, vlunteers, emplyees and ther campers. Any phts r messages that are linked r tagged frm friends and attached t yur site(s) r prfiles(s) that are inapprpriate shuld be remved. All participants must nt pst phts taken anywhere at the camp that are inapprpriate (e.g. bathhuse, cabins, etc.) All participants must nt use bscenities, prfanity, r vulgar language. All participants must nt use blgs r persnal websites t disparage the Metrplis f Pittsburgh, ther campers, r staff f the Metrplis f Pittsburgh Camping Prgram. All must participants must nt use blgs r persnal websites t harass, bully, r intimidate ther campers r staff f the Metrplis f Pittsburgh. Behavirs that cnstitute harassment and bullying include, but are nt limited t: Cmments that are dergatry with respect t race, religin, gender, sexual rientatin, clr, r disability Cmments that are sexually suggestive, humiliating, r demeaning Threats t stalk, haze, r physically injure anther persn All participants must nt use these venues t discuss engaging in cnduct prhibited by camp plicies and an Orthdx Christian lifestyle, including, but nt limited t, the use f alchl and drugs, sexual behavir, sexual harassment, and bullying. Campers may friend request / fllw Staff. Staff thugh, are nt permitted t initially cntact campers t request t be friends r t fllw Campers. Any camper fund t be in vilatin f any prtin f this plicy will be subject t immediate disciplinary actin, up t and including dismissal at the discretin f the Camping Ministries Crdinatr and Summer Camp Sessin Chaplain. If such events are discvered after the camping seasn has ended (Facebk, Twitter, Instagram, YuTube psting, etc.) discipline may result, including remval frm all future Metrplis Yuth Ministry Prgrams. Fr Questin r Cncerns, please cntact the Camp Ministries Crdinatr: // camp@pittsburgh.garch.rg.

8 Nte: The Clergy and Summer Camp Staff reserve the right t ask yu t change yur clthing if they feel that what are wearing is inapprpriate. Please see ur Metrplis Dress Cde Vide available n ur YuTube Statin: Due t the fact that we are in a camp setting, dress is casual. Please pack cmfrtable clthing. In keeping with the Orthdx Christian family envirnment, ur Metrplis camp prgram requires mdest clthing. Please pack enugh as yur camper will nt be able t wash clthes during the sessin! Clthing with messages: N clthing with lgs that cntain prfane language, reference t drugs, alchl, tbacc, and vilent r anti-christian prpaganda will be permitted. Tatts/Bdy Piercings: Cnsistent with the Orthdx teaching f respect fr the bdy as a temple f the Hly Spirit, all participants in ur prgram may nt have any visible tatts, branding r bdy piercings. (If yu have a visible tatt, yu must keep it cvered with a bandage. Males, if the tatt(s) are n yur chest/arm, yu must wear a shirt while swimming.) Earrings: Males may nt wear earrings. Females may wear n mre than tw earrings in each ear. Any additinal earrings/piercing which may be visible must be remved prir t camp. (This includes belly, nse, and tngue piercings.) Wmen & Girls: Mid-sectin (waist, hips) must be cvered at all times. Tube tps, halter tps, tank tps, spaghetti straps, bikinis, tankinis, r 2-piece bathing suits are nt permitted (even in the bathhuse r cabin). N shrt shrts r shrt mini-skirts. Yga pants and leggings are permitted nly if a female s bttm is cvered. Overly tight fitting r lw cut apparel is als nt allwed. Men & Bys: Please wear swim trunks n Speeds permitted. N saggy-baggy pants t be wrn belw the hips and n shrt-shrts. N bxers may be wrn as uterwear r are allwed t extend abve r belw shrts r pants. Lacrsse jerseys and cut-ff t-shirts are nt permitted. Fr Chapel: Fr all participants, during Vespers each evening and at Divine Liturgy, n shrts r flipflps are permitted. Bys must wear lng pants r jeans (n hles). Girls must wear cnservative lng pants, jeans (n hles), skirts r casual dresses/jumpers. Skrts are acceptable if the length is mid-thigh r lnger. Please nte, many f ur campers and staff chse t bring a nicer utfit fr Divine Liturgy n Thursday during each sessin. Fr Outdr Activities: The camp envirnment requires that campers cme prepared fr varius weather cnditins and utdr activities. Campers must cme with lng pants/jeans, sweatshirts/jackets, tennis shes and/r all-terrain shes. Fr Questin r Cncerns, please cntact the Camp Ministries Crdinatr: // camp@pittsburgh.garch.rg.

9 Blanket r Sleeping Bag Sheets, Pillwcase, & Pillw Mdest ne-piece Swimsuit (Girls) Mdest swim trunks (Bys) Beach Twel(s) Bath Twels and Wash Clth Brush and Cmb Shamp and Dedrant Tthbrush and Tthpaste Sap and Sap Dish/Bdy Wash Kleenex Flashlight Insect Repellent (N aersls) Sunscreen Rain Gear Sweater/Sweatshirt/Jacket Tennis Shes, Sandals, Flip Flps/Shwer Shes, Church Shes Scks fr Tennis Shes Underwear Clthes fr messy Activities (Arts & Crafts, mud fun, etc.) Clthes fr daily Vespers and weekly Divine Liturgy (see Dress Cde Plicy) Shrts (N shrt-shrts r spandex) Summer T-Shirts Pajamas Ball Cap, Hat, Bandana Jeans/Pants r Skirts Baseball Glve (Optinal) Large Plastic Bags (Fr Dirty Clthes) Laundry Bag & Hangers Persnal Bible (Age Apprpriate Bibles will be prvided) Ntebk/Pen Bttled Water (Optinal) Travel Alarm Clck (Optinal) Camera (We cannt be respnsible fr misplaced/damaged digital cameras.) Writing Paper/Stamps Family Pictures (Yung nes ften benefit frm having a cmfrting reminder f hme.) Spending Mney ($30 - $40 suggested. Please allw fr meals t camp/ging hme frm camp fr thse travelling the lng distances by the bus.) Snacks Nthing with NUTS, please. Prayer Rpe Aersl sprays Alchl Cigarettes & tbacc prducts Drugs (except medicatins) Electrnics Firewrks Grills r Hibachis Laptp Cmputers Laser pinters Lighters and Incense Laser pinters Magazines Perishable Fd Pets Pcket Knives Weapns (f any kind) Other items nt apprpriate fr camp If in dubt, call and ask!

10 During the ONLINE registratin prcess, yu will be asked t read and accept the fllwing Terms and Cnditins fr the registratin t be entered. Belw, we ask fr bth a Parent/Guardian and the Camper t agree and sign acknwledgement f this. I/we will print, cmplete the Camper Health Recrd in its entirety and this Signature Frm. I/we will present bth frms upn arrival at Summer Camp fr registratin. N camper will be permitted t stay at camp withut the cmpleted frm (see Camper Health Recrd fr further instructins.) I/we agree that ur child will abide by all the plicies and guidelines set frth by the Metrplis f Pittsburgh and the Greek Orthdx Archdicese f America. I/we give cnsent fr ur child t attend and participate in the entire Camp Sessin requested, included all (athletic, etc.) activities. If this is nt pssible, a letter in writing r must be received by June 1 st. I/we agree t keep camp a safe place fr everyne which means abslutely n bullying behavir. I/we als agree that if ur child has t return hme due t discipline vilatins, it will be at ur wn expense and I/we will be respnsible fr transprtatin. I/we understand that curfew vilatins are grunds fr immediate dismissal frm camp. N partial sessin refund will be given. I/we give cnsent t the use f any pht, film, r videtape taken during the camp sessin fr publicity deemed apprpriate by the Metrplis f Pittsburgh. I/we will be respnsible fr transprtatin fr ur child t/frm camp and will nt permit him/her t drive t camp. I/we will agree t the Mbile Technlgy Plicy. My camper(s) will turn in all f their technlgy (e.g. cell phnes, ipads, etc.) upn arrival at camp. If they are later fund t still be in pssessin f their technlgy r any ther prhibited item, this is grunds fr immediate dismissal. I/we agree t abide by the Archdicese Scial Netwrking and Blgging Plicy. I/we agree t abide by the Metrplis Dress Cde Plicy and will nt pack r bring anything frm the Leave at Hme list. I/we understand that we are permitted t request 1 r 2 Bunk Mates prvided the tw campers are within ne year f age with each ther. We will d ur best t hnr these request, but make n guarantees. I/we agree that if deemed necessary by the Camp Ministries Crdinatr, bag searches f anyne wh is suspected f pssessing items prhibited at camp may be required. The search will take place in the presence f at least the Camp Ministries Crdinatr and a member f the Clergy. I/we understand that fd allergy restrictins (see Camper Health Recrd) and will make sure that we have nted all medically diagnsed fd allergies. I/we agree nt t pack any snacks with nuts including items prcessed with nuts. I/we agree t bring a hard cpy f the Camper Health Frm t camp fr registratin, and t send an advance cpy via t medfrms@pittsburgh.garch.rg at least ne week prir t arrival. I/we understand that prmpt ntificatin is needed if a camper must cancel. There is a $50 minimum prcessing fee fr all cancellatins. All cancellatins must be made at least tw weeks prir t the beginning f the sessin. If cancelled less than tw weeks prir t the start f camp, a 50% refund may be given nly if requested in writing r by . I/WE (PARENTS & CAMPERS) AGREE TO ABIDE BY ALL THE METROPOLIS POLICIES, TERMS, AND CONDITIONS AS LISTED ABOVE. Camper Name Signature Sessin Applied Fr Parent/Guardian Name Signature Date

11 Please submit this cmpleted release frm with the Camper Health Recrd and the Plicies, Terms, and Cnditins Frm and bring it t Camp Registratin. Name f Camper (Please Print Clearly) All campers will have access t the Lw Rpes Curse, and the ldest GOYAns will have access t the high rpes curse as part f ur prgramming. Please indicate belw whether yur child has permissin t participate r nt by circling Yes r N and signing each sectin. T ensure the safety f yur children, each sessin will be led by the prfessinally-trained staff members. Please be assured that n child will be frced t participate if they d nt chse t d s, even if yu have indicated that they may participate. Hwever, they will nt be permitted t participate if yu have indicated N n this frm. The Lw Rpes Curse is a series f wden and cable elements under 10 high that the camper wrks thrugh with his r her cabin-mates under the supervisin f the Camp Staff. These elements are designed t challenge each grup t wrk tgether, prblem slve, and develp themselves as a team. The High Rpes Curse, which will be available t ldest GOYAns, is a series f elements frm the grund up t 35 high that the campers will wrk thrugh as an individual under the supervisin f the Camp Staff. Campers will be supprted by a belay system and will navigate the elements as an individual while being in the air. The cntinuus belay system allws the participant t navigate all the Rpes Curse elements while cntinually being hked int the curse. The Rpes Curse and Zip Line have bth been inspected t meet the standards f the Pennsylvania Amusement Ride Inspectin Act. A. My Child has permissin t participate in the Lw Rpes Curse YES r NO Parent/Guardian Signature B. My child has permissin t participate in the High Rpes Curse. Yes r NO Parent/Guardian Signature Date _ Fr Questin r Cncerns, please cntact the Camp Ministries Crdinatr: // camp@pittsburgh.garch.rg.

This is very important info about camp please read all pages.

This is very important info about camp please read all pages. Camper Infrmatin Packet Nick and Kelly Children s Heart Camp 2017 This is very imprtant inf abut camp please read all pages. Camp dates are: Mnday, July 23 t Friday, July 27 Our 2018 Camp Theme is: Space