MIDWEST DIOCESE CAMP W. Grant Avenue - Third Lake, IL

Transcription

1 MIDWEST DIOCESE CAMP W. Grant Avenue - Third Lake, IL midwestdiocesecamp@gmail.com Diocesan Kolo of Serbian Sisters Serbian Orthodox Diocese of New Gracanica Midwestern America 1. CAMPER INFORMATION Name Date of Birth (mm/dd/yy) Age 2. PARENT INFORMATION Mother (Full Name) Grade this Fall Gender Male Female T-shirt Size Camper is baptized or converted in Orthodox faith Yes No This is camper s first time at camp Yes No Youth S (6-8) Youth M (10-12) Youth L (14-16) Youth XL (18-20) Adult Small Adult Medium Adult Large Adult X-Large Father (Full Name) Address City State Zip Parent Address Home Phone Mother Cell Father Cell 3. PARISH INFORMATION Church Name City/State Signature of Parish Priest Date 4. APPLICATION & FEES IMPORTANT Registration is based on availability and completed applications received no later than May 31 Incomplete applications will not be processed and may result in the camper not being enrolled for summer camp Completed health forms must be submitted before the start of camp (we will accept physicals less than one year old) Only completed applications and full camp fee, postmarked by May 1, will qualify for early/discounted fee Mail application and check made payable to: MIDWEST DIOCESE CAMP, Attn: Nellie Balach, 3 Circle Ridge Court, Burr Ridge, IL Teen Week is for high school incoming Freshmen through Graduated Seniors (Freshmen: please attach proof ID, schedule, etc.) Questions? us at midwestdiocesecamp@gmail.com APPLICATIONS & FEES ARE DUE BY MAY 31, 2018 EARLY/DISCOUNTED FEES - Application & Fees submitted by MAY $150 (ages 6-16) / $175 (teen week) REGULAR FEES Application & Fees submitted MAY 2 - MAY $175 (ages 6-16) / $200 (teen week) NON-CHURCH MEMBER FEES $215 (all ages) 2018 CAMP SEASON: JUNE 24-JULY 28 CHECK THE WEEK(S) YOUR CHILD WILL ATTEND AND THE AMOUNT DUE JUNE 24 - JUNE 30 JULY 1-JULY 7 JULY 8-JULY 14 (AGES 6-16) (AGES 6-16) (AGES 6-12) JULY 15-JULY 21 (AGES 11-13) JULY 22-JULY 28 (TEENS-HIGH SCHL) $150 (by May 1-EARLY) $150 (by May 1-EARLY) $150 (by May 1-EARLY) $150 (by May 1-EARLY) $175 (by May 1-EARLY) $175 (May 2-May 31) $175 (May 2-May 31) $175 (May 2-May 31) $175 (May 2-May 31) $200 (May 2-May 31) $215 (Non-Member) $215 (Non-Member) $215 (Non-Member) $215 (Non-Member) $215 (Non-Member) 5. PARENT I give permission for my child to attend and participate in all camp activities. I agree to cooperate with all regulations and understand that the camp fee is NON-REFUNDABLE.

2 EMERGENCY CONTACT & MEDICAL HISTORY FORM EMERGENCY CONTACT INFORMATION CAMPER NAME EMERGENCY CONTACT NAME RELATION TO CAMPER EMERGENCY CONTACT (HOME) EMERGENCY CONTACT (CELL) FAMILY PHYSICIAN FAMILY DENTIST INSURANCE INFORMATION Do you carry medical/hospital insurance? Yes No Insurance Carrier: MEDICAL HISTORY ALLERGIES Asthma Yes No Ear Infections Yes No Food Allergies Yes No Bleeding/Clotting Yes No Heart Disease Yes No Hay Fever Yes No Chicken Pox Yes No Hypertension Yes No Insect Stings Yes No Convulsions Yes No Measles Yes No Penicillin Yes No Diabetes Yes No Seizure Disorder Yes No Poison Ivy Yes No IF YOU ANSWERED YES TO ANY OF THE ABOVE, PLEASE EXPLAIN: CURRENT MEDICATIONS: DIETARY RESTRICTIONS: CHRONIC/RECURRING ILLNESS OR MEDICAL CONDITION: OTHER IMPORTANT INFORMATION: PERMISSION TO DISPENSE MEDICINE Acetaminophen can be given for a temperature above 100, earache, and/or headache Yes No Benadryl can be applied for insect bites, rashes, and/or itching PERMISSION FOR TREATMENT Yes No I hereby give my permission to the medical personnel selected by the camp director to order x-rays, treatments, and release of any records necessary for insurance purposes, and to provide or arrange any transportation for treatment including hospitalization for the above named person. PARENT

3 MEDICAL RELEASE FORM (TO BE COMPLETED BY A HEALTH CARE PROVIDER) MEDICAL RELEASE Midwest Diocese Camp requires that all participating in its summer program, which involves physical activity, have a completed statement of health from a physician or physician representative. This statement must be submitted with the application form. CAMPER NAME TO BE COMPLETED BY A HEALTH CARE PROVIDER ALLERGIES None Has the following allergies: DIETARY RESTRICTIONS None Has the following dietary restrictions: CURRENT TREATMENT None Undergoing treatment for the following condition: CURRENT MEDICATIONS None Will take the following medication(s) at camp (name, dose, frequency) : LIMITATIONS None Will require the following limitations or restrictions to activity: ADDITIONAL INFORMATION: Provide any additional information camp should be aware of: HEALTH CARE PROVIDER This is to certify that I have examined the camp applicant have found him/her physically fit to attend Midwest Diocese Camp and to participate in all activities, except as noted above. NAME OF HEALTH CARE PROVIDER (Print)

4 PARENTAL CONSENT FORM PARENTAL CONSENT PLEASE READ CAREFULLY EACH OF THE ITEMS LISTED BELOW. Your full cooperation and understanding will result in a happy and memorable camp experience for your child. þ CHECK-IN & CHECK-OUT þ MEDICAL CARE þ FIELD TRIPS þ CELL S þ DIETARY NEEDS þ CLOTHING þ BEHAVIOR þ REFUNDS Camp check-in is every Sunday from 2:00 p.m. to 4:00 p.m. Camp check-out is every Saturday from 8:00 a.m. to10:00 a.m. In the event that I am unable to pick up my child on Saturday, it is my responsibility to contact a camp committee member to inform them of who has permission to bring my child home. In the event that my child becomes ill or sustains an injury while in the care of Midwest Diocese Camp at Third Lake, Illinois, I, the undersigned parent or guardian, grant authority to the camp clergy or camp staff member to act on my behalf in obtaining medical treatment necessary. In the event of an accident or medical need, I will be responsible for all medical or other additional expenses, and will not hold responsible the Midwest Diocese Camp, the Serbian Orthodox Diocese of New Gracanica-Midwestern America, or the Diocesan Kolo of Serbian Sisters. I hereby give permission for my child to take supervised field trips while attending Midwest Diocese Camp at Third Lake, Illinois. I am aware that while on a field trip, my child is able to make purchases including, but not limited to, snacks and souvenirs. All spending money will be deposited with the camp treasurer on the day of registration and my child will receive his/her envelope containing spending money prior to departing for the field trip. Any leftover monies will be collected upon return from the excursion and the envelope will be returned to the parent/guardian at check-out. I am aware that cell phones and any electronic devices must be turned in to the camp committee at time of check-in and will be given to camper for use on excursions. If my child has severe allergies to certain foods or has special dietary needs (i.e., glutenfree), I am aware that it is my responsibility to provide food/snacks for the week(s) enrolled. Wearing clothing deemed immodest/inappropriate by the camp clergy or camp staff member will result in refused participation in camp activities until properly dressed (refer to dress code on packing list and website). If no appropriate clothing is available, I am aware that I will have to return to camp to bring appropriate clothing. Any behavior unbecoming a camper at a monastery camp will result in immediate dismissal. I accept full financial responsibility for damages caused by my child during his/her stay as a camper. I am aware that no refunds will be issued for any reason. PARENT/GUARDIAN

5 CAMPER CODE OF CONDUCT & RULES CODE OF CONDUCT & RULES By checking the box in front of each category, I am indicating that I have reviewed these Camp Rules with my parent/guardian and agree to abide by the rules. I understand that if I fail to follow any of these rules I could be disciplined and/or sent home from camp at the discretion of the Camp Director. In the event that I am sent home, no refund will be given. Following these rules will help camp be a safer, happier environment for everyone. BEHAVIOR CLOTHING - Camper will show respect to our church, clergy, camp staff, other campers, and camp property - Intentional property damage will be paid for by the parents/guardians of those responsible - Inappropriate behavior will be dealt with by camp staff and committee - Serious infractions of camp rules will result in immediate dismissal - Camper will wear modest, appropriate clothing while at camp - If clergy or staff find clothing to be immodest/inappropriate, more suitable clothing will be required APPROPRIATE CHURCH CLOTHING GIRLS: BOYS: Dresses or skirts not shorter than knee length, shoulders covered at all times No pants or shorts; no tops that reveal navel/midriff area Khaki pants or dress slacks; polo or dress shirt with a collar No jeans, shorts, t-shirts, gym shoes INAPPROPRIATE CAMP CLOTHING Shorts above mid-thigh; writing on backside of shorts or pants; halter tops; exposed midriff area; vulgarity/profanity on any clothing PROHIBITED SCHEDULE WELLNESS CELL S - Inappropriate language of any kind is prohibited - Verbal or physical abuse and bullying will not be tolerated and will result in immediate expulsion - Smoking/drugs/alcohol is prohibited and if discovered will result in immediate dismissal - Food & drink are not allowed in dorm rooms at any time; all meals and snacks are provided by camp - Camper will follow camp schedule - Permission from camp director or staff member is needed to miss any service or activity - Lights out at 10 PM unless otherwise notified by camp staff or clergy - Medication brought to camp will be turned in at registration - Medication will be labeled with user s name and instructions and administered by adult in charge - Camper must bring his/her own sheets, blanket, pillow and pillow case - Cell phones and electronic devices will be turned in at time of check-in S CAMPER PARENT