This is the registration and forms packet!
This is the CampHERO registration and forms packet! You have three options for completing your registration and forms: IMPORTANT! Your spot is NOT reserved until you have completed the following steps! 1) Register for CampHERO using the printable registration form in this packet (page 1-2) or online at www.badgerlandcamps.org. 2) Submit your payment. 3) Complete and return all forms The entire information packet and payment must be submitted to secure an open spot. Incomplete packets will be considered as pending and will not be processed until all paperwork is received. Open spots will be filled in the order that completed registration packets are received. When the maximum number of registrations is reached, a waitlist will be created. 1) Complete the forms in this packet Sign everything with your electronic signature Save the document as "Your Camper's name-CampHERO" Pay with credit/debit (or mail payment separately) Email to: [email protected] 2) Complete the forms in this packet Print the forms and sign manually Mail forms and payment to: GSWIBC, ATTN: Program Registrar 2710 Quarry Rd., La Crosse, WI 54601 3) Complete the on-line registration and CampDoc forms at www.badgerlandcamps.org (available in February 2014) Digital Signatures Your signature is requested numerous times in this document. If you are signing electronically, you will have to save the document each time you insert a signature. The first time, save the document as "Camper's NameCampHERO" Each subsequent time, save it under th same title and answer "yes" to the 'replace existing document question. The second parent signature is optional There are a number of ways to insert a digital signature in Adobe Reader. Right click on the signature block and follow the instructions OR Look for the "Sign" tab in the upper right corner of the page. If you need further assistance, check out the video linked below. Learn how to insert a digital signature by clicking this link. CampHERO Forms Guide Complete ALL the forms on the following pages. Forms Checklist: Registration Form Health History Forms. Code of Conduct Travel and Media Release Form Waiver, Release and Indemnification Agreement Why are there so many forms? Good question! CampHERO follows the guidelines of several organizations, including Girl Scouts USA & The American Camping Association, to ensure camper health and safety. We collect information that will help our staff help campers have a great experience. In addition, our partners, who allow us the use of facilities & equipment, require waivers. We know it’s a-lot, but it’s necessary! CampHERO 2014 Registration Form Online registration is also available at www.badgerlandcamps.org. A separate registration form must also be completed for each camper Camper Information – Girl Scout Membership Information Camper’s Name: _______________________________________Parent/Guardian Phone: (_____) _________________ Address: ___________________________________________ City: _________________ State: ______ Zip: _________ Grade in Fall 2014:_______ Age: ______ Birth date:_________ Member of GS of WI - Badgerland Council? Yes No Troop # or Individual: _________ Name of Council, if not Badgerland:_______________________________________ If not currently registered as a Girl Scout, complete this section. Girl Scout membership covers campers with basic insurance and allows for financial assistance. I give my daughter, ___________________________, permission to join Girl Scouts of the USA. I understand thatthere are $25 National Registration dues payable for my daughter to join. Please include the $25 GSUSA registration fee with your payment. CampHERO Date:___________ Fees:________ Camper Status: New Resident Camper? Yes No ___Years at CampHERO Camper's T-shirt Size: check one Youth Small Youth Medium Youth Large Youth XLarge Adult Small Adult Medium Adult Large Adult XLarge Adult 2XLarge ADDITIONAL T-SHIRT ORDER $12 each/$15 2XL and up Youth Small Youth Medium Youth Large Youth XLarge Requested Buddy List You may request up to 3 buddies: 1. _______________________ 2. _______________________ 3. _______________________ Adult Small Adult Medium Adult Large Adult XLarge Adult 2XLarge Parent/Guardian Contact Information Preferred Communication Contact Method: E-mail US Mail (If camper is an adult please complete Emergency Contact Info only) My camper is in the custodial care of (check one) Both Parents Mother Only Father Only Other___________ Parent/Guardian Name _____________________________ Home Phone (___) _____________ Cell (___)____________ Work or alt. Phone (___)_________________ E-mail Address __________________________________________________ Parent/Guardian Name _____________________________ Home Phone (___) _____________ Cell (___)____________ Work or alt. Phone (___)_________________ E-mail Address __________________________________________________ Emergency Contact (If Parent/Guardian cannot be reached; must have permission to transport the camper): Name ____________________________ Relationship to Camper ______________ Primary Phone (_____)______________ Alternate Phone (____)_____________________________ Transportation Information: My family is interested in getting transportation to and from camp. Yes Note: transportation is not guaranteed. CampHERO staff will contact you. No Page 1 Important Note Electronic Welcome Packet & Camp Forms log-in and registration confirmation will be sent by email to the address listed on the registration form above. Confirmation will come from email address [email protected]. Method of Payment Payment Summary *Check/Cash/Credit Card for full payment is expected by May 1st or at time of registration after May 1st. If using Badgerland Bucks or Trip Certificates: submit with this form or if submitting separately, include a written explanation including the name of the camper, program, and dates attending. Total Camp Program Fees: GSUSA Membership: ($25 dues for new or renewing members) + ADDITIONAL CampHERO t-shirt(s): + Subtotal: = $12 each. $15 size 2XL and over. List sizes on page 1 Badgerland Bucks: (Certificates Enclosed) $ 0.00 - Trip Certificates: (Certificates Enclosed) - Payment Required** = Camperships available. See www.CampHERO4girls.org for more information. $ 0.00 Enclosed is a check for $_________ payable to GSWIBC. Charge my: VISA MC AMEX DISC Please check one: Payment in full $100 Registration Deposit (program fee $200+) $50 Registration Deposit (program fee $100-199) Plus $______ payment toward my account balance Please accept $_________ additional as my donation toward camperships for girls to attend camp. Card Number: ____________________________________ V-Code_________Expiration Date: ____________________ Billing Address:____________________________________ _________________________________________________ Print name as it appears on card: _____________________ Cardholder’s Signature: _____________________________ ________ (Parent/Guardian Initial) Girl Scouts of Wisconsin – Badgerland Council Refund Policy The registration deposit is non-refundable. The balance of the camp fees will be refunded only if: (1) A written request is received from the parent/guardian at least two weeks prior to the camp program session. (2) Refunds may be made for illness or critical family emergency provided a cancellation call was made and a message left prior to the session starting. In case of illness, a written refund request with a statement from the attending physician must be received within one week after the camp program session. (3) Other requests for refunds due to extraordinary circumstances will be considered at the discretion of the CEO or designee. (4) If we are unable to place your camper in any of her choices, due to the program being at capacity or due to cancellation by GSWIBC personnel for extenuating circumstances, the total amount paid, including deposit will be refunded. PLEASE NOTE: Campers who leave camp early due to homesickness, parental request, or behavior contract violations are not eligible for refunds. Parent/Guardian Consent I have read the information provided in the camp brochure and give my permission for my child to attend Girl Scout camp. I give permission for my camper to participate in all activities unless otherwise indicated on her health information. Activities may include swimming, horseback riding, out-ofcamp activities, and may include overnights as part of the camp experience. I understand that there are inherent risks in program activities and my camper agrees to follow the directions and safety rules of the instructor/guides and cooperate with them. Moreover, I understand that the instructors have the authority to discontinue participation in the program if my camper does not follow the program safety instructions and policies and/or endangers the group due to the camper’s behavior. I understand that the use of illegal substances, tobacco, and alcohol are prohibited and if used or possessed would result in my camper’s immediate departure from the program to home at my responsibility and expense. I understand that the council is not responsible for lost items. I understand that on camp arrival day, the camp personnel have the right to refuse to admit a girl to the camp who does not meet acceptable health conditions (e.g. temperature, contagious disease, lice). I authorize the director to obtain medical care for my child in the case of a medical emergency. I give my permission for my camper to be photographed/videotaped and allow GSWIBC and GSUSA to release said media for Girl Scout and camp publicity purposes. This includes print and web marketing/publications. I do not give my permission for my camper to be photographed/videotaped and allow GSWIBC and GSUSA to release said media for Girl Scout and camp publicity purposes. This includes print and web marketing/publications. Parent/Guardian Signature (Required) _____________________________________________________________ Date ___________________________ Parent/Guardian Name (Please Print) _____________________________________________________________ Mail Registration Form and Payment to: GSWIBC, ATTN: Program Registrar, 2710 Quarry Rd., La Crosse, WI 54601 If paying by credit card, you can submit by fax to 608.784.3613 or e-mail to [email protected]. Page 2 Screening Record for CAMP USE ONLY: Date screened: Medication(s) received Yes No Recent exposure to Health Form up to date: YesNo communicable disease? Yes No Camp Health Personnel Signature Evidence of illness or injury? YesNo Notes HEALTH HISTORY FORM This form is used by all campers (child & adult) attending a DAY CAMP program. Make a photocopy for your records. BRING ALL MEDICATIONS TO BE ADMINISTERED AT CAMP, IN ORIGINAL CONTAINERS, PACKED IN A ZIP-LOCK BAG AND LABELED WITH NAME. CAMPER FULL NAME DATE OF BIRTH AGE HOME ADDRESS CITY STATE ZIP CODE PARENT/GUARDIAN # 1 FULL NAME HOME ADDRESS Same as above OR complete below CITY CAMPER’S CELL PHONE NONE HOME PHONE CELL PHONE STATE ZIP CODE BUSINESS PHONE OR 2ND CELL PARENT/GUARDIAN # 2 FULL NAME HOME PHONE HOME ADDRESS Same as above OR complete below CELL PHONE CITY STATE ZIP CODE BUSINESS PHONE OR 2ND CELL IF WE CAN NOT REACH PARENTS WHO SHOULD WE CONTACT IN AN EMERGENCY NAME RELATIONSHIP AREA CODE + PHONE NAME AREA CODE + PHONE RELATIONSHIP FAMILY PHYSICIAN AREA CODE + PHONE INSURANCE COMPANY NAME AREA CODE + PHONE NAME OF POLICY HOLDER POLICY/GROUP NUMBER PARENT LOCATION DURING CAMPER STAY: HOME OUT OF TOWN- Please bring details to check in day PARENT/GUARDIAN AUTHORIZATION This health history is complete and accurate. I know no reason(s), other than the information indicated on this form why this camper, should not participate in prescribed activities except as noted Authorization of Treatment: I give permission to the appropriate personnel to care for minor illness/injuries, using over-the counter medications/procedures as authorized in the standard operating guidelines. I give permission to camp personnel to administer medications I have listed on the health history and/or physician prescribed on the physical exam. I will send medications in original containers. I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine lab tests, treatment; to release any records necessary for insurance purposes. In the event that I cannot be reached in an emergency, I hereby give permission to the physician or other appropriate medical personnel selected by the camp director or health supervisor to secure and administer treatment, including hospitalization for the person named above; and to provide or arrange necessary related transportation for me/or my child. This complete form may be photocopied for out of camp trips. Parent/Guardian Signature Parent/Guardian Signature Health Information Provided by Parent/Guardian Camper Name: ALLERGIES List all known. Attach additional sheets if needed. Medication Allergies: Check here if NONE Describe reaction(s) & management of reaction(s) Food Allergies: Describe reaction(s) & management of reaction(s) Other Allergies: Describe reaction(s) & management of reaction(s) DIET/NUTRITION Check all that apply: This camper eats a regular diet This camper has special food needs (PLEASE DESCRIBE ): This camper eats a regular vegetarian diet General Questions (check all that apply and explain below) 1 Ear Infection 6 Diabetes 11 Menstrual Cramps 16 Hearing Impairment 2 Heart Defect/Disease 7 Asthma/Breathing 12 Motion Sickness 17 Sickle Cell Trait or Disease 3 Bleeding/Clotting Disorder 8 Seizures 13 Nosebleeds 18 Fainting 4 Hypertension 9 Bed Wetting 14 Sleep Disorders 19 Wears Glasses or Contacts 5 Musculoskeletal Disorders 10 Constipation 15 Emotional Disturbances 20 Other (specifiy) Please explain any “yes” answers, noting the number of the question (attach additional sheets if needed) Which of the following has the camper had? Check all that apply Measles Chicken Pox Mumps Hepatitis Immunizations Check ONE: My daughter/I have been fully immunized and immunizations are all up-to-date. My daughter/I have NOT been fully immunized or immunizations are NOT up-to-date If you check this option, you must sign the statement below: I understand and accept the risks to my child from not being fully immunized. Signature of custodial parent/guardian: PERMISSION FOR OVER THE COUNTER MEDICATIONS The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Please check which over the counter medications we have consent to administer to your child on an as needed basis at the discretion of the Health Supervisor. NONE Acetaminophen (Tylenol) Lice shampoo Antibiotic cream Aloe Ibuprofen (Advil, Motrin) Antihistamine/allergy medicine Calamine lotion Hydrocortisone Cream Antacids Bismuth subsalicylate/Pepto-Bismol Kaopectate or Imodium AD Cough drops Cough suppressant Include this section only if medications are being brought to camp! MEDICATIONS CURRENTLY PRESCRIBED/BEING TAKENPlease list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. “Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Bring enough medication to last the entire length of stay (both prescribed & over the counter). Keep medication in the original packaging/bottle that identifies the prescribing physician (if prescription), name of the camper, name of the medication, dosage, & frequency of administration. Label all over-the-counter medications with camper’s name. This person takes medications as follows: Medication/ Reason prescribed, taken Vitamin Name or circumstances in which medication is to be given Dose & Route Frequency/ Number of times per day taken Time(s) to be administered. Check all that apply. Note: meal times are general. If medication needs to be administered at a specific time, please indicate. Breakfast Bedtime Specific time: Breakfast Bedtime Specific time: : Breakfast Bedtime Specific time: : Breakfast Bedtime Specific time: Lunch Dinner As needed a.m. p.m. Lunch Dinner As needed p.m. a.m. Lunch Dinner As needed a.m. p.m. Lunch Dinner As needed a.m. p.m. Code of Conduct Participant and Parent/Guardian Expectations Below is the Code of Conduct Participant Behavior Contract for you and your camper to read and sign. The following is an explanation of our expectations of you as the parent/guardian. Campers that violate the Behavior Contract will be sent home. Upon a violation of the Behavior Contract, the Incident Commander will call the parent/guardian(s) listed on the contract. The parent/guardian will be informed of the violation at camp and will be asked to pick up the camper. If the parent/guardian cannot come to camp, it remains the parent/guardian’s responsibility to make arrangements for someone else to pick up the camper, as soon as possible. In those instances, the parent/guardian must also call the Incident Commander to inform her of who will be picking up the camper. If the parent/guardian refuses to arrange pick up, the Incident Commander or designee, will contact the emergency contact person listed on the camper’s health form, to make arrangements. If the Incident Commander or designee cannot locate the emergency contact person or the emergency contact person also refuses to pick up the camper, the parent/guardian will be called again. If no one agrees to pick-up the camper after these steps have been taken the Incident Commander or designee will call County Social Services to arrange housing until the parent/guardian arrives. Participant Behavior Agreement I understand that my attitude and behavior are critical to my success and to the success at camp this summer. Therefore, for the good of all, I agree to abide by the following: 1. 2. 3. 4. 5. 6. 7. 8. I will try to be sensitive to the needs of each camper by performing my assigned duties, including but not limited to: unit kapers, allcamp kapers, cleanup, participating in all-camp activities, etc. I will respect the places and the people with whom I come in contact. I understand that the use of alcohol, tobacco, profane and/or threatening language, or drugs will not be tolerated, and that usage during camp will result in expulsion from my camp program. I will be responsible for my personal belongings and equipment and will not hold CampHERO /Girl Scouts of Wisconsin Badgerland Council, Inc., or any other outsider responsible for the loss or damage due to my negligence or neglect. I will treat equipment provided by CampHERO /Girl Scouts of Wisconsin Badgerland Council, Inc. or any other person with care. I will use safety equipment furnished by CampHERO /Girl Scouts of Wisconsin Badgerland Council, Inc. for my own safety. I will treat other campers and staff with respect and courtesy. I understand that if I do not abide by the guidelines listed above, the camp director will notify my parents/guardians, and I will be sent home. I also understand that if I am sent home early due to misconduct, I will not receive a refund. I have read, understand and agree with the above responsibilities of my daughter. I have read, understand and agree to fulfill my responsibilities as a parent/guardian. Parent/Guardian Signature Parent/Guardian Signature Camper Travel and Media Release Form In order to assure the safe release of all campers to their legal parent/guardian, or other person as designated by the parent, this form must be provided to the CampHERO personnel when the camper is dropped off. No child will be released without this form. See your CampHERO Welcome Packet for more information about this form. Camper Name: Camper Home Phone: Camper Cell Phone: City: Address: State: Zip: Media Consent (choose one) I give my permission for my camper to be photographed/videotaped and allow CampHERO, GSWIBC and GSUSA to release said media for Girl Scout and Camp publicity purposes. This includes print and web marketing/publications. I do not give my permission for my camper to be photographed/videotaped and allow CampHERO, GSWIBC and GSUSA to release said media for Girl Scout and Camp publicity purposes. This includes print and web marketing/publications. Please note: If you do not give permission, you camper will not be allowed to appear in ANY pictures including those taken by other campers. They will be required to wear name tags that state "NO PICTURES" at all times. Travel Information Describe how your daughter is traveling to/from camp (ex: car with family, air-unaccompanied minor): I am requesting an earlier or later drop off or pick up time. (Note: we can not accomodate all requests) Explain: List the person(s) that are authorized to pick up your camper (including parents). Campers will ONLY BE RELEASED TO THE PERSON(S) LISTED HERE! 1) Full Name: Identification/Driver’s License Number: Full Address: Relationship to Camper: 2) Full Name: Phone: Identification/Driver’s License Number: Full Address: Relationship to Camper: Phone: By signing this form I affirm that those persons listed are aware that they will be required to show photo identification when they pick up my child, INCLUDING PARENTS! No child will be released without this form being completed. CampHERO /GSWIBC Staff Use Only Date of Release_____________________________________________Signature____________________________________________ The Adult to whom the camper is released: Print Name ________________________________________________ Identification #______________________________________ Staff Signature___________________________________________________ Date___________________ WAIVER, RELEASE, AND INDEMNIFICATION AGREEMENT I, parent of 1. and/or (camper) in consideration of being permitted to participate in CampHERO, hereby acknowledge and agree as follows: I understand the nature of the activities I/my child may perform while involved in field training activities, known as CampHERO, requires mental judgment and a degree of physical fitness, agility, and dexterity, and that this may include exercise which requires physical fitness, strength and stamina in varying environmental conditions, including confined spaces, elevated temperatures, smoke, and falling/flying debris. This may involve wearing of special protective gear including a SelfContained Breathing Apparatus (SCBA) and the use of specialized equipment which may be heavy and cumbersome. While there will be trained individuals assisting at the program, I will participate in events with others; these fellow participants will be civilians with no firefighting or EMS skills. Initials 2. I understand that field training involves the risk of injury or death, and I voluntarily assume these risks. I understand and agree that it remains my/my child’s decision to participate in all or any part of the program; and I further understand and agree that I/my chile may discontinue active participation at any time and simply participate as an observer. Initials HEALTH INSURANCE 3. I understand that The City of Madison and Madison College will not provide medical or health insurance coverage to me during any aspect of my/my child’s participation in the program/activity described herein. I hereby represent and warrant that I am/we are and will be covered throughout the activity by a policy of accident and health insurance that provides coverage for injuries I/my child may sustain in the course of my participation in the program/activity. I understand I may be required to show proof of insurance coverage prior to my/my child’s participation in the program/activity. Initials INDEMNIFICATION 4. I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby agree to indemnify, defend and hold harmless the City of Madison and Madison College and each of the foregoing entities’ employees, agents, and representatives, from any and all liability whatsoever for any and all damages, losses, or injuries (including death) sustained to person or property or both, including but not limited to any claims, demands, actions, causes of action, judgments, expenses and costs, including attorneys fees, which arise out of, result from, occur during, or are connected in any manner with my/my child’s intentional and/or negligent conduct during my participation in the program/activity or that arise out of or are in any way connected to my/my child’s participation in CampHERO. Initials RELEASE OF LIABILITY 5. To the extent authorized by law, I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby release and forever discharge The City of Madison and Madison College, each of the foregoing entities’ employees, agents, and representatives, from any and all liability, loss, damage or expense, including attorneys fees, that they or any of them incur or sustain as a result of any claims, demands, actions, causes of action, damages, judgments, costs or expenses, including attorneys fees, which arise out of, occur during, or are in any way connected with my intentional and/or negligent conduct during my/my child’s participation in the program, or that arise out of or are in any way connected to my participation in CampHERO. Initials 6. To the extent that I, individually, or my heirs, successors, assigns, or personal representatives bring a claim of any kind whatsoever against The City of Madison and Madison College, each of the foregoing entities’ employees, agents, and representatives, I agree that this Waiver, Release and Indemnification Agreement is to be construed under the laws of the State of Wisconsin and that if any portion hereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal force and effect. In signing this document, I hereby acknowledge that I have read this entire document, that I understand its terms, that by signing it I am giving up substantial legal rights I might otherwise have, and that I have signed it knowingly and voluntarily. Initials 7. I understand and agree that any and all disputes arising out of or in connection with my participation in CampHERO shall be litigated only in the Dane County, and in no other court, and I hereby consent to the jurisdiction of this court. Initials 8. I certify that I am a member of the agency or employee listed on my application, if applicable, and that the agency or employer listed is aware of and supports my participation in this program. Initials 9. I certify the information provided on this Waiver, Release and Indemnification Agreement is true and accurate. Initials 10. I understand and agree that I am responsible for attending all safety training required by the class in which I am enrolled. I understand that I must abide by all the rules and policies set forth by The City of Madison and Madison College. I understand that the rules and guidelines of CampHERO are intended to protect me and other participants from harm, to protect property from damage, and to make my learning experience and the learning experience of other participants enjoyable. I understand that my failure to abide by the rules and policies may result in my being denied admission to the event or may result in my being dismissed from the event. Initials PHOTOGRAPHS/VIDEO 11. I hereby grant full permission to Madison College and The City of Madison, to prepare, use, reproduce, publish, distribute and exhibit my name, picture, portrait, likeness or voice, or any or all of them in or in connection with the production of web sites, still photography, motion picture film, television tape, film or sound track recording, scientific publication for informational or any other professional purpose deemed by Madison College or The City of Madison necessary in the interest of the college’s/city’s mission. Initials 12. I hereby waive all rights of privacy or compensation for me, which I may have in connection with the use of my name, picture, portrait, likeness of voice, or any or all of them, in or in connection with said web sites, still photography, motion picture film, television tape, film or sound track recording and nay use to which the same or any material therein may be put, applied or adapted by Madison College. This consent and waiver will not be made the basis of a future claim of any kind against Madison College and nay of its agencies, including defamation and invasion of privacy claims. Initials Participant Name (Printed): Parent/Guardian Signature Parent/Guardian Signature
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