1. automotive and vehicles
2. campers and rvs

Camp Juliena 2015
Save This Form
Clear Form (Start Over)
Youth Camp Registration
Registration Deadline: May 15, 2015
July 19-25, 2015 • Ages 6-12
Youth Camp Juliena is an ACA accredited week-long residential summer camp for kids ages 6-12 that are deaf or hard of
hearing. Through challenging and fun activities, campers form lasting friendships and acquire valuable leadership, teambuilding, social and communication skills. Summer is fast approaching so reserve space for your camper soon! We can’t wait!!
REGISTRATION FEES
Camp Tuition*
Registration Fee**
Total Cost
Before May 15, 2015
$210
$20
$230
After May 15, 2015
$210
$40
$250
*Partial scholarships are available for camp tuition. Scholarship requests should be submitted with completed camper registration forms outlined below.
**Submission of the Registration Fee along with the “Camper Application” page of the Camp Juliena Registration forms will ensure a spot for your camper. The
remaining registration forms and fees must be received by June 20, 2015.
REGISTRATION CHECKLIST
All items must be received by Camp Juliena for registration to be considered complete
 Camper Application
 Camper Medical and Emergency Contact Information
 Camper Health Form (Physician Recommendations )†
 Copy of health insurance card
Enter Amount
 Registration fee ($20 before May 15; $40 after May 15)
$
 Tuition fee
 Total tuition is enclosed
$
 Partial tuition is enclosed
$
 Scholarship request form (optional)
 I would like to make a donation to support a camper or for general purpose
Total Amount Enclosed:
$
$ 0.00
To reserve your space at Camp Juliena, send completed forms and fees to:
Camp Juliena
Georgia Council for the Hearing Impaired, Inc.
4151 Memorial Drive, Suite 103-B
Decatur, Georgia 30032
For information, please contact us at
[email protected]
or call Bonna at (770) 856-2492
Please make checks payable to Camp Juliena.
†Must be completed by a physician if camper has dietary or other health restrictions, conditions, or prescription medications. Otherwise,
parent/guardian may write “N/A” and sign the form.
Camp Juliena: Youth Camp Application
Page 1 of 5
Youth Camp Juliena 2015 - Camper Application
Camper’s Name:
Birth Date: ___________
Address:
Gender:  M  F
City:
State:
Race/Ethnicity:  African-American
Zip Code:
 Asian
County: _______________
 Caucasian
 Hispanic
 Native American
Parent/Guardian Name: ____________________________________________________
Home Phone:
 Other
__________
Cell Phone:
Email Address:
Camper’s School:
Degree of hearing loss:  Deaf
 Hard of Hearing
Hearing augmentation:  Hearing Aid
 Speech Impaired
 Cochlear Implant
Age of Onset: ________
 No Aid/Implant
How did you learn about Camp Juliena? Select One
Camper’s t-shirt size (Choose One):
Child:  Small
 Med
 Large
Adult:  Small
 Med
 Large
 X-Large
Scholarship Request
Please understand that GACHI receives a limited amount of donations to provide camper scholarships. If your child
receives a scholarship but is not able to attend camp, please contact us immediately. If you accept scholarship money,
but do not bring your child to camp, you may be asked to pay back the money.
How much can you pay? (must be something) _____________________
How much financial aid are you requesting? _______________________
Please give us a brief explanation of your family’s current situation and why your child deserves a scholarship:
For office use only
Amount approved:
Camp Juliena: Youth Camp Application
Supervisor:
Date:
Page 2 of 5
Youth Camp Juliena 2015 – Camper Medical and Emergency Information
Participant/Camper Medical and Emergency Information Disclosure
Camper Name: _________________________________________ Age: ________ Weight: _________ Height: ________
Immunizations: Immunizations are up to date:  Yes  No
Date of Last Tetanus Shot: _________________
Current Health History
Allergies
List ALL current/chronic conditions:
Food Allergies:
List additional disabilities (physical, mental, psychological):
Drug Allergies:
List other diseases/disorders:
Other Allergies:
Past Medical Conditions - Please list past medical conditions, surgeries, or injuries:
Current Medications
Name of Medication
Dosage
How many
times per day?
What time of day?
How Given?
(oral, inhaler, etc.)
Will this medication
be given during camp?
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
All prescription drugs and medications must be in their original containers and must be turned over to Camp Juliena Staff at check-in.
Physical Limitations/Activity Restrictions:
Insurance Information **Please enclose a copy of your insurance or Medicaid card**
 I have the following type of insurance:  Medical/Hospital  Medicaid
 I do not have health insurance.
Insurance Company:
Policy/Group No:
Ins Subscriber’s Name:
Social Sec. Number:
Current Physician:
Physician Phone:
Ins Claim Address:
Pre-Authorization Phone:
**Please enclose a copy of your insurance or Medicaid card**
Emergency Contact Information
Primary Contact
Secondary Contact
Name:
Name:
Relationship:
Relationship:
Phone (Day):
Phone (Day):
Phone (Night):
Phone (Night):
For girls: Has she menstruated? Yes No
Camp Juliena: Youth Camp Application
If not, has she been informed? Yes No
Page 3 of 5
Youth Camp Juliena 2015 - POLICIES AND AGREEMENTS
Camper Name: _________________________________________ Age: ________ Weight: _________ Height: ________
Parent/Guardian Pledge and Signature: By signing this form, I hereby give permission for my
son/daughter/charge to attend Camp Juliena at Camp Viola. I affirm that he/she is physically able to care for
himself/herself, is able to participate in regular camp activities, and is of high moral standing. I also
understand that my son’s/daughter’s/charge’s picture/video may be used in promotional materials such as
brochures, newsletters, and videos. I understand that neither Georgia Council for the Hearing Impaired nor
Camp Viola will be liable for any illness, injury, or accident.
Parent’s/Guardian’s Permission to Treat: This health history is correct so far as I know, and the person herein
described has permission to engage in all camp activities except as noted by me. I hereby give permission to
the Physician selected by the Camp Director to order x-rays, routine tests and treatment for the health of my
child, and in the event I cannot be reached in any emergency, I hereby give permission to the Physician
selected to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery
for my child as named above. I understand Camp Viola, Camp Juliena, nor Georgia Council for the Hearing
Impaired, Inc. are liable for any illness, injury, or accident of a camper or visitor.
Cancellation and Refund Policy: Upon request, 75% will be refunded if canceled up to three (3) weeks prior to
camp. No refunds after that time.
Parent/Guardian Signature:
Camp Juliena: Youth Camp Application
Date:_______________
Page 4 of 5
Youth Camp Juliena 2015 – Physician Recommendations and Restrictions
(While at Camp Juliena)
If a camper requires a special diet (other than simple dietary changes) or prescription medications while at camp, the
information on this page MUST be completed by a physician. If not, parent/guardian may write camper’s name, indicate
N/A, and sign the bottom of this page.
Camper Name: _______________________________________________________
Special Diet Instructions
Prescription Medications to be administered at camp
Name of Medication
Dose
Frequency
Route of Admin (how given)
All prescription drugs and medications must be in their original containers and must be turned over to Camp Juliena Staff at check-in.
Activities which camper cannot participate in
Does this person have any communicable diseases?  Yes  No (if yes, please list and explain on back)
Date of last visit:__________________
This person herein described is under my care and in my opinion this person is physically able to engage in
camp activities, except as noted above.
Parent signature:_________________________________________________
OR
Physician:
Date:___________________
Telephone:
Address:
City:
State:
Zip:
Mail or fax to:
Camp Juliena
Georgia Council for the Hearing Impaired, Inc.
4151 Memorial Drive, Suite 103-B
Decatur, Georgia 30032
Fax: (404) 299- 3642
Camp Juliena: Youth Camp Application
Page 5 of 5