CAMP VALOR 2015 August 3-7 Utah Hemophilia Foundation 772 East 3300 South, Suite 210 Salt Lake City, UT 84106 (801) 484-0325/ Toll Free 877-463-6893 www.hemophiliautah.org Camp Valor Teen Program Changes have been made to this program. Please read the following before applying Due to limited space in the Camp Valor Teen Program, not all applicants will be accepted. The following is required to be considered for participation: Priority will be given to teens with a bleeding disorder or who have been diagnosed as a carrier. Must be between the ages of 14 and 16. Have the maturity to relate to peers and adults in a positive manner. Have the ability to communicate and work with other teens and adult volunteers. Maintain a positive and cooperative attitude with all members of the Teen Program and Camp Valor staff. Be physically able to participate in activities on a daily basis and other group related experiences. *Teen applications will not be accepted after July 6, 2015 No Exceptions! *Financial assistance is available if the registration fee is hardship. Please fill out and submit “Request for Financial Assistance” form, available on the UHF website. Camp Valor Teen Program August 3—7, 2015 Application Form TEEN APPLICATIONS WILL NOT BE ACCEPTED AFTER JULY 6, 2015. _________________________________________________________________________ Teen’s Last Name First Name Preferred Name/Nickname ________________________________________________________________________ Address City State Zip ________________________________________________________________________ Home Phone Number Birth Date (MM/DD/YYYY) Male/Female ________________________________________________________________________ Parent /Guardian Name Parent Cell Phone Number Teen Cell Phone Number ________________________________________________________________________ Parent/Guardian Email Address Teen Email Address Bleeding Disorder Status (check one): (Priority given to those with bleeding disorders and diagnosed as a carrier) TYPE: Payment Enclosed: $70 reduced registration fee if received at the UHF office by June 5, 2015. $80 registration fee if received between June 6 and June 22, 2015. $90 registration fee if received between June 23 and July 6, 2015 Paid online with my Mastercard, Visa, Discover or AmEx, through Firstgiving.com 1. 2. 3. 4. Go to www.firstgiving.com/uhf Click on the green Donate button on the right side of the screen Enter requested credit card information—use fee scale as listed above Enter “Camp Valor Registration” in the Comments section ‘Request for Financial Assistance’ form. Make checks payable to the UHF and mail with registration form: Utah Hemophilia Foundation 772 East 3300 South, Suite 210, Salt Lake City, UT 84106 Phone: 801-484-0325 /Toll Free: 877-463-6893 Fax: 801-746-2488 Please have the teen applicant answer the following questions completely, using additional pages if necessary. Please give an example of how you support the Utah Hemophilia Foundation in accomplishing its mission. What are the qualities or characteristics you have that would enhance the Teen Camp Program? If you had the opportunity to be in the Teen program last year at Camp Valor, please tell us about some of your favorite experiences. Please list the names and telephone numbers of three individuals, to whom you are not related and do not work at the UHF, that we may call for a reference: ___________________________________________________________________________ Name Phone Number ___________________________________________________________________________ Name Phone Number ___________________________________________________________________________ Name Phone Number Thank you for providing this information and for your interest in the Teen Camp Program. A UHF staff member or a Teen Committee volunteer may contact you to discuss this information. Consent Forms Permission to Participate in Activities and to Use Provided Transportation I hereby give permission for the above-named teen to participate in all teen activities and to use provided transportation. I freely waive all rights to any future claims against the Utah Hemophilia Foundation, Camp Wapiti, volunteers, or representatives due to any accident, injury and/or illness or treatment of the same that may occur during the camp period. Yes No ____________________________________________________ Signature of Parent or Legal Guardian Teen Signature Agreement to Comply with Camp Tobacco Policy I understand that smoking or the use of tobacco products by minors is illegal in the State of Utah and is not allowed during the Teen Leadership Program. I agree that teens who violate this policy may be expelled from the program and that their families may be required to arrange and/or pay for that teen’s transportation home. I hereby attest that I have explained this policy to the above-named teen. Yes No ____________________________________________________ Signature of Parent or Legal Guardian Teen Signature Permission to Participate in Educational Programs I hereby give permission for the above-named teen to participate in educational programs during the program, including general health education and home infusion therapy training, if appropriate. Yes No ____________________________________________________ Signature of Parent or Legal Guardian Teen Signature Release of Graphic/Photographic Rights I hereby grant the release of any film, video or other photographic images of the above-named teen and of any artwork created during the Teen Leadership Program by said teen for use by the Utah Hemophilia Foundation for fundraising, educational, or other purposes. Yes No ____________________________________________________ Signature of Parent or Legal Guardian Teen Signature Teen Leadership T-Shirt Size: Child’s Medium (10-12) Child’s Large (14-16) Adult Small Adult Medium Adult Large Adult X-Large Adult 2XL Other:___________ Teen Leadership Program Program Commitment Agreement This form explains and clarifies the mutual commitment between the teen applicant and the UHF. By completing this form, you acknowledge your understanding of and commitment to these expectations. Please initial after each to acknowledge you have read, understand, and agree to comply. As a Teen Leadership participant, I understand that I am committing to: Work constructively as a part of a team with other staff and to positively resolve all conflicts. Teen’s Initials:__________ Place the best interest of this program above my own personal feelings. Teen’s Initials:__________ Represent the UHF professionally and positively to other volunteers, teens, and the public. (including not bad-mouthing anyone associated with the UHF or its partners). Teen’s Initials:__________ Respect the confidentiality and privacy of teens and families. Teen’s Initial:__________ Notify the UHF of any potentially unethical situation or conflict involving myself or other volunteers. Teen’s Initials:__________ Provide opportunities for each teen to be successful at some experience and feel good about their experience. Teen’s Initials:__________ Set a good example for teens through appropriate speech, positive attitude, participation in activities, sportsmanship, sharing, and doing daily chores. Teen’s Initials:__________ Help enforce all regulations and safety rules. Teen’s Initials:__________ Refrain from having any personal visitors (family members and friends not associated with the Teen Leadership Program) during the week. Teen’s Initials:__________ Acknowledge that during the Teen Leadership Program, teens (along with adult volunteers) are responsible for teaching and carrying out planned camp activities. Teen’s Initials:__________ Recognize that the Teen Leadership Program is for and about bleeding disorders and not a time to develop personal, business, or social contacts. Teen’s Initials:__________ Carry out assignments and stay with them at ALL assigned camp activities. Teen’s Initials:__________ I understand that failure to comply with this Code of Conduct may result in my dismissal from the Teen Leadership Program and may prevent me from participating in future UHF activities. Signature of Teen Leadership Applicant Date Signature of Parent or Legal Guardian Date Teen Leadership Program Teen Code of Honor We expect all teens to follow the behavior expectations outlined below. BEHAVIOR EXPECTATIONS 1. I understand that everyone at the Teen Leadership Program needs to be treated with respect and I need to show respect for others’ personal belongings, privacy, and feelings. Any inappropriate touching between campers or counselors is not allowed. As well as using other’s personal belongings without permission. I understand that I can be sent home if I violate any of these expectations. 2. I understand that it is against UHF rules to be involved with smoking, alcohol use, illegal drugs, weapons (including pocket knives), vandalism, theft, or any other illegal behavior. I know and understand that I could be sent home if I have brought any of these items to camp or use them; or if I engage in ANY illegal behavior, including vandalism and theft. 4. I understand that it is against camp rules to leave the program facility unless I am on a special, escorted and approved activity or for a medical emergency that requires transportation to an outside medical facility. I know and understand I will be sent home if I leave facility premises without permission. 5. I understand that I need to respect the facility and its equipment. I understand that my parents and I will have to pay for any damage I intentionally cause. 6. I understand that I have to sleep in my assigned cabin each night. I understand it is against camp rules to “sneak out” of my cabin after curfew and that I can be sent home for this behavior. 7. I understand that at any time if any staff member or another teen feels that I am a danger to myself or anyone else, because of my behavior or something that I have said, I will be required to talk to a member of the Camp Valor Committee. I understand that I can be sent home if the director feels that it is necessary for my safety or the safety of others. 8. If I have any problems, I know and understand that I can go to my counselor or any of the adult leaders at the Teen Leadership Program. CONSEQUENCES Depending on the severity of the situation, one or more of the following consequences will be taken: I understand that my leader or a member of the Teen Leadership Committee will discuss the behavior with me. I may be not allowed to participate in a planned activity. A member of the Teen Leadership Committee may call my parents and discuss the behavior with them. I understand that I can be sent home immediately and possibly not be allowed to participate in future UHF activities, even if it is my first time not following any of the behavior expectations. I understand that if I am sent home for any reason my parents will be responsible for coming to pick me up at camp. This will be at my parent’s expense. They will not be reimbursed for travel time, time taken off work, gas, etc. My signature indicates I have read and understand the Behavior Expectations and agree to the Consequences. _____________________________ Teen Signature _________________________________ Parent/Guardian Signature __________ Date Signed CAMP VALOR 2015 Teen Medical Form This completed / signed medical form is REQUIRED to participate in Camp Valor This completed form must be sent to Penni Smith @ IHTC (contact information on last page) Form must be completed and signed by your medical professional (parent signature, only, will not be accepted). Teens who do not submit a completed medical form will not be allowed to attend Camp Valor. Teens must have a confirmed diagnosis of a bleeding disorder to participate in the Teen Camp Program. Teen Last Name First Name Preferred Name/Nickname _____________________________________________________________________ Address City State Zip (____)________________________________________________________________ Home Phone Number Birth Date (MM/DD/YYYY) _____________________________________________________________________ Weight Height Male/Female __________________________________________________(____)______________ Parent or Legal Guardian Name Cell Phone Number _____________________________________________________________________ Parent/Guardian Email Address Please list ALL medicines this individual currently uses, including pain medications: Medication Dose Frequency Special Instructions (w/ meals, etc.) ____________________ _________ _________ __________________________ ____________________ _________ _________ __________________________ ____________________ _________ _________ __________________________ ____________________ _________ _________ __________________________ ____________________ _________ _________ __________________________ Necessary medications for the week of camp should be sent with the camper’s/teen’s name clearly marked. All medications will be dispensed by the medical staff. Emergency Contact Information Please provide information for two (2) individuals who are able to be contacted regarding an emergency situation in the event that the camp medical staff is unable to reach the parents or guardians. Also provide contact information for the teen’s physician. ___________________________________________________(____)_____________ Emergency Contact Name Relationship to Teen Phone Number ___________________________________________________(____)_____________ Emergency Contact Name Relationship to Teen Phone Number _____________________________________________________________________ Teen’s Physician (____)______________________________(___)_____________________________ Office Phone Emergency/Other Phone Health Insurance Information Proof of insurance is required for campers/teen’s to attend camp—NO EXCEPTIONS. Please provide a copy of both sides of your insurance card. Name of Provider, HMO, PPO: ______________________________________________ Policy Number: ________________________ ID/Group Number: __________________ Policy Holder’s Name: ______________________ Member Number: ________________ Is pre-certification required?: Yes No Phone number:________________ Parent Consent Form Authorization for Medical Treatment I hereby authorize physicians and/or nurses to provide the above-named teen with appropriate medical treatment for his/her bleeding disorder or any other medical problems that may arise during the camp period. I understand that the camp medical staff will supervise treatment of bleeding episodes and of routine illnesses. I further understand that I may receive notification of treatment administered to the above-named teen and that copies of any treatment records made during camp may be sent to my private doctor or hemophilia treatment center for continuity of treatment. I also authorize the above-named teen to be transferred to a medical facility for emergency treatment at the discretion of the physician, nurse, camp director, or foundation representative. I will send a sufficient supply of factor and/or other medications needed to cover my teen’s needs. Yes No ____________________________________________________ Signature of Parent or Legal Guardian Date Authorization for Camp Medical Staff to Contact Camper/Parent After Camp: I hereby authorize a member of the Camp Valor Medical Staff to contact me and/or my teen to provide follow-up information and/or instruction about infusion techniques and/or further infusion classes. Yes No ____________________________________________________ Signature of Parent or Legal Guardian Date Blood Type: _________ Type of Bleeding Disorder: Factor 8 _____% Factor 9 _____% Severity of Bleeding Disorder: Platelet Disorder vWD Mild Moderate Other _________________ Severe None Has this individual ever been treated with factor concentrate? Yes No Please note: Campers/teens who require factor treatment or are on prophylaxis must bring their own supply of factor to camp with them. All campers with ports or similar medical devices must bring any necessary medical supplies (i.e. port access needles, etc.). All containers MUST be carefully labeled with the camper’s/CA’s name and any pertinent information. Brand and product this individual currently uses: _________________________________ Purity: ______________ Average Dose Required (# of units): _____________________ On average, how often is treatment required?____________________________________ Is this individual on prophylaxis? If yes, circle which days: Sun Mon Yes Tues No Wed Thu Has this individual ever had a reaction to treatment? Fri Sat Yes Sun No If yes, specify product: ______________________ Reaction: _____________________ _____________________________________________________________________ Does this individual have target joints or recurrent bleeding sites? Yes No If yes, please specify: _____________________________________________________ Does this individual have any of the following?: Port Broviac Other Please specify care/routine: ________________________________________________ Dietary restrictions: _______________________________________________ Please Note: First-time teen participants must include a copy of their immunization record. Are all immunizations up to date? Yes No Date of Last Tetanus Shot: __________________________ Please indicate any serious illnesses this individual has: Allergies Asthma Diabetes Epilepsy Heart Disease Hepatitis HIV Kidney Disease ADHD or Nervous Disorders Other __________________________ Details of all items marked above: ____________________________________________ _____________________________________________________________________ Physical limitations and required accommodations: _______________________________ _____________________________________________________________________ Please describe any recent injuries this individual has had: __________________________ _____________________________________________________________________ If this individual has a bleeding episode, what is the treatment you provide at home? ___________________________________________________________________________ ___________________________________________________________________________ What else should the staff be aware of? (Behavioral issues, psychological concerns, ): _____________________________________________________________________ _____________________________________________________________________ Medical Professional Signature: Signature _____________________________________________ Phone:_______________________________ Date:______________________________ Date of latest Hemophilia Treatment Center visit: _________________________________ Send this completed medical form to: Penni Smith Intermountain Medical & Thrombosis Center (IHTC) Primary Children’s Medical Center 100 No. Mario Capecchi Drive Salt Lake City, UT 84113 Email: [email protected] Fax: 801-662-4838
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