Camp FRESH (Fresh Resources Everyoe Should Have) The deadlie to apply is April 10. Space is limited, so do t delay! For more iformatio call 302-320-6525 Or visit www.christiaacare.org/campfresh Lear to live a healthy life for yourself ad others ad the pass those lessos o to your family, frieds ad people i your comuity. At Camp FRESH, eligible tees age 13-18 will be empowered to become ambassadors for positive chage. Campers take a close look at the sources of food i their commuities ad fid affordable utritious alteratives to uhealthy foods. It s a importat message they ca carry to their frieds, schools, churches ad govermet. Camp FRESH rus Jue 15 through August 6. Camp is free ad ope to residets of Wilmigto ad New Castle. 13-15 year-olds meet Modays ad Wedesdays, Jue 15 August 5. 16-18 year-olds meet Tuesdays ad Thursdays, Jue 16 August 6. Tees meet at Christiaa Care s beautiful Eugee du Pot Prevetive Medicie & Rehabilitatio Istitute for educatio sessios o: Health advocacy Sexual health Commuity orgaizig Nutritio Weight maagemet Plaig for the future Drug ad alcohol educatio Commuicatio Emotioal health I the afteroo, campers will reach out to people i urba eighborhoods i Wilmigto, spreadig the word about the importace of healthy food ad exercise. Camp FRESH is sposored by Christiaa Care Health System s Departmet of Family & Commuity Medicie. www.christiaacare.org/campfresh 15CHO2
February 1, 2015 Dear Camp FRESH applicats ad parets/guardias: Greetigs, I hope this letter fids you well ad ready for some summertime relaxatio away from school ad for the adults, maybe a vacatio from work! I am very excited to say that Camp FRESH 2015 is shapig up to be the best year yet for the program. The program will ru from Jue 15-August 5 for the 13-15 year-old group; ad Jue 16-August 6 for the 16-18 year-old group. As we embark o year ie, we will be usig past lessos to iform our future activities. Ad as always, whe it comes to improvig health, there s still so much more work to be doe. So, i 2015, it s all about welless. What s New? This year, we re goig to cotiue egagig the commuity, gatherig iformatio o what could make Wilmigto healthier. Of course, this all starts by esurig our Camp FRESH 2015 is the healthiest it ca be. We will do this through: Educatio Camp FRESH will educate participats o various topics icludig utritio, physical health, metal health, sexual health ad overall welless. Practical Applicatio Camp FRESH staff will lead participats through activities related to the above educatioal topics; this will iclude regular exercise ad participatio i plaed physical activities. Outreach Camp FRESH participats will give back to the Wilmigto commuity by participatig i a variety of commuity-based activities. How to Apply If you are iterested i applyig for a positio i Camp FRESH, please complete the applicatio, which is attached. It is importat that you iclude all of the iformatio requested; we will ot accept icomplete applicatios. Space is limited, so submit applicatios as soo as possible. If you have ay questios, please feel free to give me a call at 302-320-6525. Applicatios are due o April 10, 2015. All the best to you, Christopher C. Moore Sr. Program Maager, Commuity Health Departmet of Family ad Commuity Medicie Christiaa Care Health System
Camp FRESH 2015 Applicatio Checklist Applicatios are due April 10, 2015 Please be sure to iclude all of the followig iformatio: 1. Camp FRESH Registratio Form 2. Essay questios did you aswer all six? 3. Camp FRESH Nomiatio Form 4. Letter of Referece (see Nomiatio Form) 5. Camp FRESH Participat Cotract 6. Camp FRESH Liability Form 7. Camp FRESH Health History 8. Camp FRESH Physical Fitess Questioaire 9. Copy of Medicaid card Mail applicatios to: Camp FRESH c/o Departmet of Family ad Commuity Medicie 1400 North Washigto St, Floor 4 Wilmigto, DE 19801 Applicatios ca be faxed to: 302-320-2813; Or emailed to ggraves@christiaacare.org
Camp FRESH 2015 Registratio Applicatio Please prit clearly. Applicatios that are illegible will ot be accepted. Applicatios are due by Friday, April 10, 2015 Last Name: Please fill out all boxes: First Name: Address (please iclude house umber ad street ame): City: State: Zip Code: Date of Birth: Phoe Number: Please check the optio which applies to you: My family has Medicaid (if this applies to you, please sed a copy of your child s Medicaid card to address listed below) My family has private isurace (Blue Cross/Blue Shield, Aeta) My family does t have isurace/usure Essay Questios Please type, or eatly hadwrite your aswers to ALL of these questios ad submit with your applicatio. Each aswer should be i paragraph form, with thoughtful resposes which are clear ad provide examples. If you do ot complete all six questios, you will ot be cosidered for Camp FRESH. 1. What does commuity mea to you? 2. Who is your hero, ad how would you like to follow i this perso s footsteps? 3. If you could chage oe thig about your commuity to ehace or improve the lives of your family, frieds ad commuity, what would it be? How would you accomplish this? 4. What is the biggest challege you face as a teeager? What barriers do you feel are stadig i the way of you beig successful i life, or achievig your dreams? 5. How would you like to grow over this summer while you are i Camp FRESH? 6. Why should we choose you for Camp FRESH? Mail all applicatios, isurace iformatio, ad essay aswers to: Camp FRESH, c/o Departmet of Family ad Commuity Medicie 1400 North Washigto St, Floor 4, Wilmigto, DE 19801
Camp FRESH 2015 Nomiatio Form Please prit clearly. Applicatios that are illegible will ot be accepted. Applicatios are due April 10, 2015 Last Name: Nomiator s Iformatio Please fill out all boxes: First Name: Address (please iclude house umber ad street ame): City: State: Zip Code: Phoe: Email: Last Name: Studet Iformatio First Name: Nomiator s relatio to omiated studet: How log have you kow omiated studet? Why should the omiated studet be cosidered for Camp FRESH? Mail all omiatio form alog with a letter of recommedatio to: Camp FRESH, c/o Departmet of Family ad Commuity Medicie 1400 North Washigto St, Floor 4, Wilmigto, DE 19801
Camp FRESH Participat Cotract This form must be submitted alog with applicatio by April 10, 2015 I,, agree to the followig items: Camp FRESH participats will be paid $250.00 at the completio of the program. Paymet will be determied before the start of Camp FRESH either i the form of a check or a VISA gift card. Please iitial ad date that you have read this part Date Camp FRESH participats may oly miss 2 sessios. Excused abseces will be cosidered o a case-bycase basis. Excused abseces iclude: doctors appoitmets vacatios sick days family emergecies. Staff should be alerted to ay expected abseces ahead of time, if possible. Camp FRESH participats will ot utilize cell phoes for ay purpose aside from emergecy phoe calls or to arrage trasportatio. Participats may oly charge their phoes durig approved times. Cell phoes will be placed i a bag ad kept i the maager s office. Cell phoe use for ay other reaso will be grouds for beig asked to leave that day s sessio. Camp FRESH participats will be give two Camp FRESH t-shirts which they will be expected to wear every day they are at camp. Campers are expected to be wearig their t-shirts before they eter the buildig. If they are ot wearig the Camp FRESH t-shirt, they will be set home, which could potetially result i a uexcused absece. Camp FRESH participats are ot to brig i food or driks to the buildig; if campers are caught with food or driks, they will be asked to tur them over to staff. Camp FRESH provides two meals luch ad dier, alog with healthy sacks ad water. Camp FRESH participats will ot egage i acts of physical violece or bullyig, use offesive laguage, or disrespect staff or other participats. This behavior will ot be tolerated ad will be grouds for beig asked to leave the program. Camp FRESH participats who are caught stealig from staff or other participats, caught with alcohol or drugs, caught with weapos will be dismissed from the program ad will ot be eligible for ay icetives. Camp FRESH participats who are asked to leave 2 times for ay issues metioed above will be dismissed from the program. Camp FRESH staff reserve the right to sed ay tee home if their behavior is causig distruptios, i additio to aythig listed o this cotract.
Camp FRESH participats who use DART First State trasportatio will be provided with adequate bus passes for each week. Camp FRESH participat hours cout toward commuity service; however, if a tee is asked to leave the program, staff reserve the right to ot authorize the hours worked. I,, have read ad uderstad the iformatio above ad will be resposible for my ow actios as a participat of Camp FRESH. I also ackowledge that failure to follow ay of the rules set forth i this agreemet may serve as grouds for beig ieligible to receive the $250 stiped at the ed of the program. Sigature: Date: Paret/Guardia Sigature Date:
Camp FRESH Release of Liability, Statemet of Resposibility ad Photo Release Must be completed ad retured by paret or legal guardia. Please Prit Clearly or Type: Child s full ame Date of Birth Sex Male Female Street Address City State Zip Child s Email Child s Social Security Number I case of emergecy, otify (ame) Day phoe Night phoe This Agreemet cocers the risks associated with your child s participatio i Camp FRESH. It has importat legal cosequeces. The fial decisio to sed your child to Camp FRESH should oly be made after you read ad fully uderstad the terms of the Agreemet ad agree to be boud ad have your child be boud by its terms. For coveiece ad clarity, the term I refers to you, the siger (paret or guardia). My child refers to your child, ad Christiaa Care Health Services is hereafter referred to as Christiaa Care. 1. I certify that I am the paret or legally appoited guardia of the child amed above. 2. I uderstad that reasoable care ad precautio will be take to avoid accidets, that medical persoel will be available at Camp FRESH, ad that all childre participatig i Camp FRESH will be uder close supervisio. I uderstad that the program may pose risks of illess or ijury because it ivolves vigorous activity, gatherigs of groups of people, ad outdoor settigs. I retur for Christiaa Care acceptig my child ito Camp FRESH, I release Christiaa Care ad its employees ad voluteers from all liability which may result from my child attedig Camp FRESH, usig the facilities, ad/or participatig i Camp FRESH evets, icludig ay ijury to my child or damage to my child s property, or ay ijury to aother perso caused by child. 3. I uderstad that if my child becomes ill or is ijured while at Camp FRESH, the staff will cotact me ad I will be resposible for pickig up my child. 4. I hereby give permissio to Christiaa Care ad its employees ad voluteers to use photographs take of my child while attedig the Camp FRESH, for the purpose of promotig the program ad/or ay other programs sposored by Christiaa Care Health System. Icludig use of photos o Christiaa Care s website Not icludig use of photos o Christiaa Care s website By sigig below, I state that I fully uderstad all the coditios of this Agreemet ad agree to be boud by, ad to have my child be boud by all its terms. Prit Name of Paret or Guardia Sigature of paret/guardia
Camp FRESH 2015 Health History Form You must complete ad submit with applicatio; applicatios submitted without a health history form will ot be cosidered. A complete ad accurate health history is eeded i order for Camp FRESH staff to provide high quality care. The Camp FRESH applicatio will ot be cosidered complete uless this form is complete. A Paret/Legal Guardia must complete this form i pe. Please prit all iformatio. Studet s Name (Last) (First) (MI) Does your child have ay allergies? (food, medicatio, latex)? Does your child have ay dietary restrictios/eeds (i.e. o pork products, vegetaria optios oly) Please provide the followig iformatio about medicies your adolescet is takig. Name of medicies Reaso take How log take Has your adolescet ever bee hospitalized overight? Age Problem Has your adolescet ever had ay serious ijuries/illess? Has your child bee see by a health care provider i the past year? Name of provider: Reaso(s) for visit(s): Has your child bee see i a emergecy room withi the last year? Reaso(s) for visit(s): Has your child bee see for a detal visit i the last year? Has your child ever bee hospitalized or received couselig for emotioal health? Reaso:
Please idicate which of the followig your CHILD has ever had: Diabetes Hepatitis Sickle Cell Depressio High Blood Pressure Aemia Faitig Spells High Cholesterol Frequet Colds Kidey/Bladder Disease Arthritis Headaches Head Ijury Rheumatic Heart Disease Cacer Heart Disease Heart Murmur Seasoal Allergies Tuberculosis If ay of the above is checked, please give more detail. I the past year, have there bee ay chages i your family such as: Marriage Serious Illess Chage i school Births Divorce Separatio Loss of Job Move to a ew house Deaths Other Please check ay of the followig illesses that your FAMILY MEMBERS (paret, brother, sister, gradparet, aut, ucle, etc.) have ever had ad idicate which family member ext to the illess. oid Disease PARENTAL/GUARDIAN CONCERNS Below are some commo cocers of adolescets ad families. If you have ay of these cocers, please ecourage your child to talk to the staff social worker, or you ca feel free to call the Camp FRESH maager (302-428-6525) to discuss your cocers. Weight/Diet/utritio Sleep Patters Smokig cigarettes/chewig tobacco Choice of frieds Self image/self worth Depressio Lyig, Stealig, or vadalism Violece School grades truacy/dropout Relatioships with family members Drug/Alcohol use Sexual behaviors Sexual idetity Excessive moodiess or rebellio If you would like assistace with establishig Isurace, fidig a doctor, or a detist, please call the Christiaa Care Marketplace Guide Program Office at 302-320-6586. Name of perso completig form: Relatioship to studet: Date: Camper: Date of applicatio:
Camp Fresh Physical Fitess Questioaire 1. What is your curret height ad weight? ft iches, lbs 2. I kow what a healthy weight is for me. YES NO If so what is it? pouds 3. Are you comfortable with your curret weight? YES NO a. If ot, what are your weight-related goals (i.e. wat to lose 10lbs, toe up belly, build larger muscles, etc)? 4. I thik about the healthfuless of the foods I am eatig? YES NO SOMETIMES 5. How may total servigs of fruits ad vegetables do you eat daily? 0 1-3 4-6 >7 6. I kow somewhere i my eighborhood to buy fresh fruits ad vegetables? YES NO a. If so, where: 7. Circle the meals you regularly eat below most days of the week: a. Breakfast Sack Luch Sack Dier Sack 8. How may servigs (1c, 1 slice or 8oz) of dairy products do you get daily? 0 1-3 4-6 >7 9. How may meals a week do you average are from fast food? 0 1-3 4-6 >7 10. How would you describe your family s attitude regardig eatig healthy/stayig fit o a scale of 1 to 5, with (1) beig ot importat ad (5) beig importat? 1 2 3 4 5 11. Do you have ay family members who have a utritio related disease(s)? Circle below: a. Diabetes High blood pressure Obesity High cholesterol 12. O average, how may days do you exercise per week for 1 or more hours cotiuously? 0 1-2 3-5 6-7 13. I would like more iformatio o how to get i better shape both utritioally ad physically this summer? YES NO For office use oly: BMI: RMR: BMI dx: uderwt/ormal/ overweight/obese /morbidly obese Group: MW TR
DON T FORGET A COPY OF YOUR MEDICAID CARD!