Day Camp Brochure. Girl Scouts of Kentuckiana Area 8 Seussical Adventures 2115 Lexington Road Louisville, KY DATED MATERIAL

Transcription

1 Day Camp Brochure Girl Scouts of Kentuckiana Area 8 Seussical Adventures 2115 Lexington Road Louisville, KY DATED MATERIAL Area 8 Day Camp Seussical Adventures July 16-20, am 4 pm Camp Shantituck-Shepherdsville, KY Girl Scouts $90 camp fee Transportation Fee $25 REGISTRATION DEADLINE: APRIL 30, 2018

2 Do you have some time you can give to camp? This camp is staffed by volunteers who give their time freely so that all interested girls may attend camp. We are looking for adults to help provide this wonderful experience for girls. To accommodate all the girls who want to attend camp, lots of adults are needed. No previous experience is required! All volunteers receive training for their job and support from other adults. Volunteering at camp is a unique opportunity to positively impact your camper and have a great time doing it! Volunteers are needed to work directly with units and also to offer special programs such as crafts, photography, environmental activities, and so on. In fact, almost any skill or interest you can share can probably be used! Archery Fire Building Nature Education Sketching Bicycling Whittling Canoeing Outdoor Cooking Storytelling Camp Craft Games Dramatics First Aid/CPR Weather Nature Crafts Pioneer Crafts Hiking Singing Help us protect you and your camper! Here at GSK, the health and safety of our girls is our top priority. All camp volunteers must be members of the Girl Scouts and complete a criminal background check. To volunteer, please visit our website at and click on the Volunteer button below the picture. Membership is $25 and expires on September 30 th of the current troop year. Once you complete your membership registration, you will receive an with directions on how to submit your criminal background check. This background check costs $8 and is good for three years. Who May Attend Any girl may attend camp; however, she must join the Girl Scouts. Visit our website at and click on Join. Membership is $40 and expires September 30 th of the current troop year. However, we suggest taking advantage of the new Extended Troop Year! Starting May 1 st, a girl can sign up to be a girl scout, pay $50 and her membership will not expire until September 30 th of the NEXT troop year. This saves the family $30 and ensures her girl scout experience continues past camp! Financial Assistance Financial assistance is available to registered Girl Scouts. Mail the Financial Assistance Request with your other camp forms to the camp registrar. The Girl Scout office will notify both you and the camp registrar of the decision concerning your financial assistance. Each family must be prepared to pay some portion of the fee. Refunds The camp registration fee may be refunded for a cancellation due to illness, family emergency, or relocation. Check with your camp registrar for details. Lost and Found Please label all belongings with your name. Promptly contact the camp director about lost items. Girl Scouts of Kentuckiana and camp staff cannot be responsible for loss of or damage to campers personal belongings. Website More information about camps can be found on the GSK website Just follow the Camps link and then Day Camps & Camporees. Resident Camp Fun! Resident camp is the heart and soul of the summer camp experience. Caring Counselors guide girls to make life long memories, new friends, and discover the pleasure of the outdoors. Girls will be challenged to try new things and will come back a more courageous and confident girl of character. Register via MyGS by May 31 st. Troop Camping Is Here! If your troop is looking for an extra camping experience this summer bring them to Troop Camp Plus at beautiful Camp Pennyroyal! Your troop chooses the length of your stay, participates in council led programming from 10-5, and night activities are completely up to you! Register through MyGS starting April 1 st! Girl Scouts of Kentuckiana:

3 SEUSSICAL ADVENTURES AREA 8 GIRL SCOUT DAY CAMP JULY 16-20, 2018 CAMP SHANTITUCK, EAST HEBRON LANE, SHEPHERDSVILLE, KY TERRI MASSEY, DAY CAMP DIRECTOR OR tmassey13@gmail.com THEME: Seussical Adventures. Come and find the places you can go at Area 8 Day camp. Adventures in camping, hiking, creekwalking, arts and crafts, swimming, archery, stem and steam activities all in the beautiful outdoors. ACTIVITIES & OPPORTUNITIES BY AGE Campers entering K-3 rd grade-traditional day camp Campers entering 4 th -5 th grade-traditional day camp + 1 overnight + archery Campers entering 6 th grade-traditional day camp + 1 overnight + archery + rock climbing Campers entering 7 th grade-adventure crew-traditional day camp + offsite 2 nights at Camp Stem with canoe/kayak, high ropes, caving, and archery Mentors-In-Training-girls entering 8 th grade- teen mentor development program. Prerequisite: Teen Mentor Core training offered through council and Area 8 MIT training sessions Teen Mentors-girls entering 9 th -12 TH grade-formerly Program Aides. Assist in delivering program to younger girls OVERNIGHT OPPORTUNITIES Campers entering 4 th grade and older-wednesday July 18, th graders stay in Denham house. Girls are expected to stay the whole night. In the case of inclement weather, all campers will stay in buildings. Teen mentors will be assigned to HUB to help deliver the all camp overnight program. Teen Mentors: Teen Mentor only overnight-thursday July 19, A fun night of camp just for the Teen Mentors. TEEN MENTOR AND MIT SPECIAL SESSIONS Teen Mentor Trainings-Teen mentors are expected to attend the Teen Mentor Training and are invited to attend the Site Training and Day Camp Leadership volunteer trainings. MIT s are expected to attend the MIT planning and training sessions and the Teen Mentor Core Training TRANSPORTATION: Transportation will now be separate fee from camp registration and will be $25 for each girl or MIT (teen mentors, volunteers, boys, and pixies do not pay transportation fee). THIS FEE WILL NOT BE PRO-RATED. Bus locations are Oldham County High School and Shelby County Departure 7:45 am SHARP. Please arrive by 7:30 am for check-in. Return 4:45 pm. Please arrive by 4:30 to be ready to pick up your camper(s) Please place the color-coded wrist band on your camper. DO NOT REMOVE until end of day Friday. Pick-up: Please have the car tag displayed in the windshield with the camper number facing out so the bus monitor can release your child Please be considerate of the bus monitors. They are volunteers and must stay until all campers are picked-up. TRAINING FOR VOLUNTEERS, TEEN MENTORS, AND MENTORS-IN-TRAINING We want you to have an enriching experience as you work with these amazing young girls and women. Sharing your skills and talents makes camp happen. Training requirements: All adults are expected to participate in training. If you attended leadership and site training in the past 5 years, you only need to complete the Take Home Training. Step 1: Take Home Training packet-read and complete the test in the packet that will be ed upon receipt of your registration. All adult volunteers and teen mentors must complete this step. There is new information this year! Step 2: Day Camp Leadership Training-Attend ONE of these offerings (Adults and Teen Mentors welcome and encouraged) May 16, 2018 at Oldham County Park in Buckner., KY 6:30 pm 8:30 pm May 17, 2018 at Diane Price s Home 1170 Harrington Mill Rd. Shelbyville, KY :30 pm 8:30 pm Step 3: Teen Mentor Training (Teen Mentor s only)-attend ONE of these offerings May 23, 2018 at Oldham County Park in Buckner, KY. 6:30 pm 8:30 pm May 24, 2018 at Diane Price s Home 1170 Harrington Mill Rd. Shelbyville, KY :30 pm 8:30 pm Step 4: Site Training (Adults and Teen Mentors welcome and encouraged) May 30, 2018 at Camp Shantituck. 6:30 pm 8:30 pm. Bring water bottle and wear shoes and socks. Outdoor training: Each unit requires an adult volunteer with outdoor training. For day campers-camp In A, for overnighters, Camp In A & B for buildings and Camp Out for tents. Outdoor Training Weekend-you can get all of these trainings or just one during this training weekend. Go to the GSK website and select training to register. May 18-20, 2018 at Camp Shantituck

4 REGISTRATION INSTRUCTIONS REGISTRATION INSTRUCTIONS: PLEASE FOLLOW INSTRUCTIONS CAREFULLY All registration must be postmarked by 4/30/18 TO BE ON-TIME. LATE FEE: $50 per camper/boy/pixie NO REGISTRATIONS WILL ACCEPTED AFTER 5/15/18 Payment must accompany registration, unless payment will be with GSK credits, financial assistance, or Joyce Seymour Scholarship-Mail financial assistance request along with registration to the camp registrar Registrations accepted first come/first serve with preference given to campers with fulltime, then part-time volunteers Camp maximum capacity is 325 persons-campers, teen mentors, volunteers, pixies, and boys. Child/Adult ratios must be maintained. Confirmation of registration, instructions, packing list, unit assignments, name tags, and bus wrist bands will be sent to your home the week of June 11, 2018 Camp registration fee may be refunded for special circumstances such as illness, family emergency, or a move. Requests must go to the camp director-terri Massey FEE SCHEDULE GIRLS AGES 5-18 PIXIES AGE 3-5 & BOYS AGE 5-12 ADULT VOLUNTEERS Girl Camper K-7 TH Grade $90 Mentor-In-Training 8 TH Grade $90 Teen Mentors 9 TH -12 TH Grade $25 Non-Girl Scouts K-12 (GSUSA REG) $40 *THIS FEE IS IN ADDITION TO CAMP FEE Transportation fee (riding bus) $25 LATE FEE: $50 PER CAMPER AFTER 4/30/18 NO REGISTRATIONS ACCEPTED AFTER 5/15/18 Pixies (Potty trained) $25.Wk or $5/day Boys age 6-12 $85Wk or $25/day Patch for pixie or boy $2 LATE FEE: $50 PER PIXIE OR BOY AFTER 4/30/18 NO REGISTRATIONS ACCEPTED AFTER 5/15/19 GSUSA Registered Adults $0 Non-registered Adults $25 Part-time adult t-shirt $12 Background check $8 Background checks due every 3 years ALL ADULTS MUST BE GSUSA REGISTERED *Please do not hesitate to call for financial assistance prior to the deadline of 4/30/18-Terri Massey or tmassey13@gmail.com Registration Checklist 1. Make sure all registrations are complete & include all signatures and requested documents. 2. Please use blue or black ink and write legibly 3. Use this checklist to ensure your registrations are complete 4. Incomplete registrations will not be processed until all documents and signatures are complete 5. Registration due date: April 30, Late fee: $50 per camper, pixie, and boy 7. No registrations will be accepted after May 15, 2018 Registration form #1 complete for all girls in K-8 th grade, all pixies, and all boys Health history complete (on back of form #1) for all girls K-8, all pixies, and all boys Registration form #2 complete for all Teen Mentors in 9-12 grade Health History complete (on back of form #2) for all Teen Mentors in 9-12 grade Registration form #3 complete for all adult volunteers Health history complete (on back of form #3) for all volunteers Payment-check &/or GSK rewards card number and a picture of the front and back of the card Self-addressed stamped legal-size envelop with 2(two) first class stamps Financial assistance request if applying Make check payable to: Area 8 Day Camp Mail to Area 8 Day Camp Registrar. C/O Jamie Farley Briarhill Rd. Crestwood, KY Questions: Call the Camp Director: Terri Massey or tmassey13@gmail.com

5 Camp Registration Form #1 Youth-GIRLS, MIT S, BOYS, & PIXIES Complete one for each youth camper and mail to your camp registrar. Please PRINT clearly and legibly in blue or black ink Camp Name (not campsite) AREA 8 DAY CAMP SEUSSICAL ADVENTURES Dates of Camp JULY 16-20, 2018 Camp Site CAMP SHANTITUCK Camper Information Campers Name (Last, First, MI) Address (Street, City, State, Zip Birth Date Age Grade in Fall Troop # Request Placement with Other Scout Placement requests are not guaranteed. Girls must be in same Girl Scout grade level for consideration. Registration Type General Camper - $90 Non-Scout - $90 Plus $40 Girl Scout Registration Fee Mentor In-Training $75 Pixie-$25 (Children of Volunteers Only) Boy - $85 (Children of Volunteers Only) Bus Transportation fee - $25 (no charge for volunteers, teen mentors, boys, & pixies) Transportation Preference Oldham County High School -Buckner Shelby County-First Christian Church 1000 Eminence Pik Car Optional Overnight Permission-For girls entering 4 th grade and older-note: If you think your daughter might change her mind, please check yes. Your daughter will not be able to change her mind from not staying to staying once camp has started. By checking yes, you give permission for your daughter to spend the night at Camp Shantituck on Wednesday July 18, 2018 Will your camper plan to spend the night on Wednesday July 18, 2018? (check ): Yes No Pixies and boys do not spend the night. Our youngest campers sleep inside a building. Custodial Parent / Guardian Information Camper is in the custody of (check ): Both Parents Mother Only Father Only Other: Mother/Guardian Name Father/Guardian Name PERMISSIONS FOR AREA 8 DAY CAMP SEUSSICAL ADVENTURES JULY 16-20, 2018 Please initial each individual permission, blanks will be considered as not giving permission Swimming Permission: My daughter/son has my permission to swim daily at Camp Shantituck during the week of July 16-20,2018. NOTE: ALL SWIMMERS WEARING FLOATATION DEVICES MUST STAY IN THE SHALLOW END. My child must wear ear plugs when swimming My child must wear a floatation device when swimming-floatation devices not provided-must bring own 7 th Grade Adventure Crew-girls entering 7 th grade. My daughter has my permission for off-site trip Tuesday July 17-Thursday July 19, 2018 to Camp Stem in Laconia, IN and Indian Lake in Tell City, IN. Will include transportation, canoe/kayak, and High Rope Adventure session. 6 th Grade only: Rock Climbing permission: My daughter has my permission to go Rock Climbing at Rock Gem during Area 8 Day Camp the week of July 16-20, Transportation will be provided. PARENT/GUARDIAN SIGNATURE: DATE: Mail To: Area 8 Day Camp Seussical Adventures c/o Jamie Farley 6905 Briarhill Rd. Crestwood, KY MAKE CHECK PAYABLE TO: AREA 8 DAY CAMP Date Received Receipt Number For Registrars Use Only Amount Paid In: Cash Check Kentuckiana Credits Financial Assistance Total Paid

6 Health History Form Complete one for each youth and adult camper and mail to your camp registrar. Please PRINT clearly and legibly. Campers Name Birthday Emergency Information: Custodial Parents/Guardians Names Emergency Contact (if parent/guardian cannot be reached.) Name Relationship to Camper Camper s Physician Office Phone Insurance Carrier Policy # Group # If hospitalization is required, take camper to Allergies: Check those that apply, specify nature and if treatment requires the use of an Epipen, Benadryl, etc.) Allergy Nature of Allergy / Treatment Allergy Nature of Allergy / Treatment None Hay Fever Animals Medicine/Drugs Food Insect Sting Plants Other: Illnesses, Injuries or Health Conditions: (check those that apply) None Bed Wetting Headaches Motion sickness ADD/ADHD Bleeding/Clotting Disorder Heart disease/defect Seizures Asthma Diabetes Hearing Impairment Other: Immunizations Immunizations are up to date. Family chooses not to immunize. Date of last Tetanus shot: Health Supervisor Permission for Medications: (check those that apply) Camper may take acetaminophen (ex: Tylenol). Yes No Camper may take oral antihistamine (ex: Benadryl). Yes No Camper may take ibuprophen (ex. Advil) Yes No Camper may use topical antihistamine (ex: Benadryl). Yes No Camper may use antibiotic ointment (ex: Neosporin). Yes No Camper may use topical hydrocortisone (ex: Cortizone) Yes No If you checked yes to any illnesses, injuries or other health conditions, please attach a separate sheet of paper with explanation. Give nature, dates, period of any disability and results. Also, list any activities that should be restricted. Information about medications: Is camper taking any medication? Yes No If yes, attach a list of the camper s current medications to this form; send a list of any medication changes or updates the first day of camp. Medications for campers under the age of 18 must be kept in the possession of the health supervisor at all times (unless otherwise noted) Any medication to be dispensed should be indicated on the Health History Form. All medication, including over-the-counter products, should be in the original container and marked clearly with the participant s name and directions for use. Prescribed medications and over-the-counter products must be administered in the prescribed dosage by or in the presence of the health supervisor or as per the written instructions of a custodial parent, a guardian, or a physician. Medication can only be dispensed to the person named on the prescription container. As per the Safety-Wise chapter of Volunteer Essentials, medications, including over-the-counter products, cannot be dispensed without prior written permission from a girl s custodial parent or guardian. HEALTH INFORMATION PRIVACY STATEMENT FROM GSUSA The Health History Form is for health care concerns at this camp only. All medical records will be held in limited access by the health care supervisor of this camp. Minimally necessary information may be shared with camp staff/volunteers in order to provide adequate participant safety and health care. The health history form will be retained by GSK along with all forms/records with noted treatment for seven years past the age of maturity of the participant. Access to the information will be limited. I have read the above procedures for handling the health form information and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. Parent s or Guardian s Statement & Signature - My camper has had a physical examination within the past 24 months and is in good health. I give full permission for my camper to attend camp and participate in all activities (except as noted on this health history.) The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of injuries, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of my camper for Girl Scout promotional purposes. I agree that all information including immunizations is complete and up to date. Volunteer Statement & Signature - I am in good health and able to participate in all activities at camp (except as noted on this health history.) The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of an injury, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of me for Girl Scout promotional purposes. Parent/Guardian or Volunteer Signature Date:

7 Camp Registration Form #2 Teen Mentors only (Girls entering 9 th -12 th grade) Complete one for each youth camper and mail to your camp registrar. Please PRINT clearly and legibly in blue or black ink Camp Name (not campsite) AREA 8 DAY CAMP SEUSSICAL ADVENTURES Dates of Camp JULY 16-20, 2018 Camp Site CAMP SHANTITUCK Camper Information Campers Name (Last, First, MI) Address (Street, City, State, Zip Birth Date Age Grade in Fall Troop # Request Placement with Other Scout T-Shirt Size (check ): YS YM YL AS AM AL AXL AXXL AXXXL Placement requests are not guaranteed. Girls must be in same Girl Scout grade level for consideration. Teen Mentor (PA) $25 Registration Type Transportation Preference Oldham County High School -Buckner Shelby County-First Christian Church 1000 Eminence Pik Car Teen Mentor Optional Overnight Permissions- By checking yes, you give permission for your daughter to spend the night at Camp Shantituck Will your Teen Mentor plan to spend the night on Wednesday July 18, 2018? (check: ) Yes No Will your Teen Mentor plan to spend the night for Teen Mentor only night on Thursday July 19, 2018? (check ) Yes No Custodial Parent / Guardian Information Camper is in the custody of (check ): Both Parents Mother Only Father Only Other: Mother/Guardian Name Father/Guardian Name PERMISSIONS FOR AREA 8 DAY CAMP SEUSSICAL ADVENTURES JULY 16-20, 2018 Please initial each individual permission, blanks will be considered as not giving permission Swimming Permission: My daughter/son has my permission to swim daily at Camp Shantituck during the week of July 16-20,2018. My child must wear ear plugs when swimming PARENT/GUARDIAN SIGNATURE: DATE: Please check the areas you are interested in: (Requests honored based on the needs of camp and the girls) Daisy s Brownies Juniors Cadettes Pixies Boys Special Programs: Archery Stem/Steam Fishing Photography Mail To: Area 8 Day Camp Seussical Adventures c/o Jamie Farley 6905 Briarhill Rd. Crestwood, KY MAKE CHECK PAYABLE TO: AREA 8 DAY CAMP Date Received Receipt Number For Registrars Use Only Amount Paid In: Cash Check Kentuckiana Credits Financial Assistance Total Paid

8 Health History Form Complete one for each youth and adult camper and mail to your camp registrar. Please PRINT clearly and legibly. Campers Name Birthday Emergency Information: Custodial Parents/Guardians Names Emergency Contact (if parent/guardian cannot be reached.) Name Relationship to Camper Camper s Physician Office Phone Insurance Carrier Policy # Group # If hospitalization is required, take camper to Allergies: Check those that apply, specify nature and if treatment requires the use of an Epipen, Benadryl, etc.) Allergy Nature of Allergy / Treatment Allergy Nature of Allergy / Treatment None Hay Fever Animals Medicine/Drugs Food Insect Sting Plants Other: Illnesses, Injuries or Health Conditions: (check those that apply) None Bed Wetting Headaches Motion sickness ADD/ADHD Bleeding/Clotting Disorder Heart disease/defect Seizures Asthma Diabetes Hearing Impairment Other: Immunizations Immunizations are up to date. Family chooses not to immunize. Date of last Tetanus shot: Health Supervisor Permission for Medications: (check those that apply) Camper may take acetaminophen (ex: Tylenol). Yes No Camper may take oral antihistamine (ex: Benadryl). Yes No Camper may take ibuprophen (ex. Advil) Yes No Camper may use topical antihistamine (ex: Benadryl). Yes No Camper may use antibiotic ointment (ex: Neosporin). Yes No Camper may use topical hydrocortisone (ex: Cortizone) Yes No If you checked yes to any illnesses, injuries or other health conditions, please attach a separate sheet of paper with explanation. Give nature, dates, period of any disability and results. Also, list any activities that should be restricted. Information about medications: Is camper taking any medication? Yes No If yes, attach a list of the camper s current medications to this form; send a list of any medication changes or updates the first day of camp. Medications for campers under the age of 18 must be kept in the possession of the health supervisor at all times (unless otherwise noted) Any medication to be dispensed should be indicated on the Health History Form. All medication, including over-the-counter products, should be in the original container and marked clearly with the participant s name and directions for use. Prescribed medications and over-the-counter products must be administered in the prescribed dosage by or in the presence of the health supervisor or as per the written instructions of a custodial parent, a guardian, or a physician. Medication can only be dispensed to the person named on the prescription container. As per the Safety-Wise chapter of Volunteer Essentials, medications, including over-the-counter products, cannot be dispensed without prior written permission from a girl s custodial parent or guardian. HEALTH INFORMATION PRIVACY STATEMENT FROM GSUSA The Health History Form is for health care concerns at this camp only. All medical records will be held in limited access by the health care supervisor of this camp. Minimally necessary information may be shared with camp staff/volunteers in order to provide adequate participant safety and health care. The health history form will be retained by GSK along with all forms/records with noted treatment for seven years past the age of maturity of the participant. Access to the information will be limited. I have read the above procedures for handling the health form information and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. Parent s or Guardian s Statement & Signature - My camper has had a physical examination within the past 24 months and is in good health. I give full permission for my camper to attend camp and participate in all activities (except as noted on this health history.) The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of injuries, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of my camper for Girl Scout promotional purposes. I agree that all information including immunizations is complete and up to date. Volunteer Statement & Signature - I am in good health and able to participate in all activities at camp (except as noted on this health history.) The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of an injury, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of me for Girl Scout promotional purposes. Parent/Guardian or Volunteer Signature Date:

9 Camp Registration Form #3- Adult Complete one for each adult camper and mail to your camp registrar. Please PRINT clearly and legibly. Camp Name (not campsite) AREA 8 DAY CAMP SEUSSICAL ADVENTURES Dates of Camp JULY 16-20, 2018 Camp Site CAMP SHANTITUCK Camper Information Volunteer s Name (Last, First, MI) Camper s Name/Names Address (Street, City, State, Zip T-Shirt Size (check ): YS YM YL AS AM AL AXL AXXL AXXXL FULL TIME ADULTS RECEIVE FREE $12.00 FOR PART-TIME ADULTS Girl Scout Membership / Trainings Are you currently a registered Girl Scout Yes No Please list the troop numbers that your camper belongs to Have you completed a Volunteer Application form within the last three years Yes No Check all that apply First Aid Certified CPR Certified Doctor, Nurse, or EMT Girl Scout Camping Trained Camp In Camp Out Wilderness Travel (Circle Highest) Transportation Preference Oldham County High School -Buckner Shelby County-First Christian Church 1000 Eminence Pik Car Names of children you will be transporting Availability Circle the days you are available: MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY ALL WEEK Are you available to spend the night on Wednesday? Circle: YES NO WHAT AREAS WOULD YOU PREFER TO VOLUNTEER (IF SCHEDULING PERMITS)? DAISY S AGES 5-6 BROWNIES AGES 7-8 JUNIORS AGES 9-11 CADETTES AGES PIXIES (POTTY TRAINED) BOYS AGES 6-12 INFIRMARY (RN/LPN/MD/EMT) KITCHEN PHOTOGRAPHY ARCHERY CRAFTS/STEM/STEAM PIXIE/BOY NAMES: PIXIES MUST BE POTTY TRAINED PER GSUSA REGULATION. CAMP REGISTRATION FORM #1-YOUTH & HEALTH HISTORY MUST BE COMPLETED FOR EACH PIXIE/BOY. NAME BOY PIXIE AGE NAME BOY PIXIE AGE PIXIES/BOYS: PATCH IS NOT INCLUDED IN FEE. IF YOU WANT TO ORDER, YOU MAY IN ADVANCE PATCH $2.00 FEE FOR BOYS IS $85/WEEK OR $25/DAY-BOYS MUST BE 12 YEARS OF AGE OR YOUNGER, NO BOYS WILL BE ALLOWED TO SPEND THE NIGHT FEE FOR PIXIES IS $25/WEEK OR $5/DAY NOTE: Units are formed by grade level. Day camp in not intended to be troop camping, therefore, units will not be made up entirely of one troop. The goals of day camp are to meet new friends, explore new and different surroundings, and experience new ideas. Parents volunteering will NOT be placed in their daughter s unit unless a medical condition necessitates. Troops with 3 or less girls will be placed together in a unit. We will try to accommodate requests for pairings, please specify on your daughter s registration if there is a buddy she would like to be paired with. ALL ADULTS MUST BE REGISTERED PER GSUSA POLICY: INCLUDES BACKGROUND CHECK AND CHILD PROTECTION TRAINING. Mail To: Area 8 Day Camp Seussical Adventures c/o Jamie Farley 6905 Briarhill Rd. Crestwood, KY Make check payable to: Area 8 Day Camp Date Received Receipt Number For Registrars Use Only Amount Paid In: Cash Check Kentuckiana Credits Financial Assistance Total Paid

10 Health History Form Complete one for each youth and adult camper and mail to your camp registrar. Please PRINT clearly and legibly. Campers Name Birthday Emergency Information: Custodial Parents/Guardians Names Emergency Contact (if parent/guardian cannot be reached.) Name Relationship to Camper Camper s Physician Office Phone Insurance Carrier Policy # Group # If hospitalization is required, take camper to Allergies: Check those that apply, specify nature and if treatment requires the use of an Epipen, Benadryl, etc.) Allergy Nature of Allergy / Treatment Allergy Nature of Allergy / Treatment None Hay Fever Animals Medicine/Drugs Food Plants Insect Sting Other: Illnesses, Injuries or Health Conditions: (check those that apply) None Bed Wetting Headaches Motion sickness ADD/ADHD Bleeding/Clotting Disorder Heart disease/defect Seizures Asthma Diabetes Hearing Impairment Other: Immunizations Immunizations are up to date. Family chooses not to immunize. Date of last Tetanus shot: Health Supervisor Permission for Medications: (check those that apply) Camper may take acetaminophen (ex: Tylenol). Yes No Camper may take oral antihistamine (ex: Benadryl). Yes No Camper may take ibuprophen (ex. Advil) Yes No Camper may use topical antihistamine (ex: Benadryl). Yes No Camper may use antibiotic ointment (ex: Neosporin). Yes No Camper may use topical hydrocortisone (ex: Cortizone) Yes No If you checked yes to any illnesses, injuries or other health conditions, please attach a separate sheet of paper with explanation. Give nature, dates, period of any disability and results. Also, list any activities that should be restricted. Information about medications: Is camper taking any medication? Yes No If yes, attach a list of the camper s current medications to this form; send a list of any medication changes or updates the first day of camp. Medications for campers under the age of 18 must be kept in the possession of the health supervisor at all times (unless otherwise noted) Any medication to be dispensed should be indicated on the Health History Form. All medication, including over-the-counter products, should be in the original container and marked clearly with the participant s name and directions for use. Prescribed medications and over-the-counter products must be administered in the prescribed dosage by or in the presence of the health supervisor or as per the written instructions of a custodial parent, a guardian, or a physician. Medication can only be dispensed to the person named on the prescription container. As per the Safety-Wise chapter of Volunteer Essentials, medications, including over-the-counter products, cannot be dispensed without prior written permission from a girl s custodial parent or guardian. HEALTH INFORMATION PRIVACY STATEMENT FROM GSUSA The Health History Form is for health care concerns at this camp only. All medical records will be held in limited access by the health care supervisor of this camp. Minimally necessary information may be shared with camp staff/volunteers in order to provide adequate participant safety and health care. The health history form will be retained by GSK along with all forms/records with noted treatment for seven years past the age of maturity of the participant. Access to the information will be limited. I have read the above procedures for handling the health form information and I agree to the release of any records necessary for treatment, referral, billing or insurance purposes. Parent s or Guardian s Statement & Signature - My camper has had a physical examination within the past 24 months and is in good health. I give full permission for my camper to attend camp and participate in all activities (except as noted on this health history.) The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of injuries, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of my camper for Girl Scout promotional purposes. I agree that all information including immunizations is complete and up to date. Volunteer Statement & Signature - I am in good health and able to participate in all activities at camp (except as noted on this health history.) The Girl Scouts of Kentuckiana is held harmless in the event of an accident. In the case of an injury, I give permission for medical treatment as deemed necessary. Permission is granted to use any pictures or video footage of me for Girl Scout promotional purposes. Parent/Guardian or Volunteer Signature Date: