ADVENTURELORE SUMMER PROGRAMS …..SAVE THIS PAGE ….CAMP PACKING LIST ON BACK… Welcome to our 2015 Adventurelore Summer Program! Our 34th year!!! For those of you coming to Adventurelore for the first time, you may be a bit nervous ahead of time, especially the night before and the morning of your trip. That’s OK- most are! Just be reassured, as soon as the activities begin, before we load up the vans, each adventurer will be one of the group and part of the fun. After a long, cold winter, take advantage of the warmer temperatures. Now is the time to get outside, take a walk, a run, or bicycle. Any physical activity you enjoy most works great! So, get out, get active and even get your family involved! Enclosed are our camp forms. Please complete, sign and return to us ASAP. Now is not too early! A $ 200.00 (non-refundable) deposit per program is necessary for registration. We are unable to hold a spot without this deposit. The deposit is deducted from the total cost of the program. We accept MASTERCARD, VISA, DISCOVER . Balance is due by June 15, 2015. *********************************************** All camp programs leave from our headquarters in Danville, NH. We provide transportation to camp locations. PROGRAMS ARRIVE @ DANVILLE: 5 Day JR 1 Woodstock (June 29 - July 3) 5 Day JR 2 Woodstock (July 13 – July 21) 6 Day JR 3 Franklin, ME (July 27 - Aug 1) Monday, June 29 @ 10:00 am Monday, July 13 @ 10:00 am Monday, July 27 @ 9:00 am 8 Day XC Challenge (June 29 - July 6) 8 Day Land & Sea (July 9 - July 16) 8 Day White Mtn. (July 21 - July 28) 6 Day GIRLS Adv. (July 20 - July 25) am Monday, June 29 @ 9:00 am Thursday, July 9 @ 9:00 am Tuesday, July 21 @ 10:00 am Monday, July 20 @ 9:00 ************************************************* Each program returns to Danville at approximately 3 pm. We will make every effort to contact you should this change. Please allow some extra time for the post–trip conferences! MONEY? Campers don’t “need” money but may wish to bring some for souvenirs, store stops, ice cream, etc. Any questions you have, we can answer! Call us @ 603-382-4661, email us @ [email protected] P.O. Box 395 197 Long Pond Rd. Danville, NH 03819 Phone (603) 382-4661 Fax (603) 382-0571 Website: www.adventurelore.org Email: [email protected] We’re ready for another FUNtastic summer. All we need is you! ADVENTURELORE PACKING LIST We recommend you use a duffle bag. On your arrival day, please bring a small day pack with your own lunch, water, bathing suit and towel. PLEASE LABEL EVERYTHING! Unclaimed clothing is donated to charity. We are not responsible for lost or stolen valuables (ipods, jewelry, etc.) Use of personal cell phones will not be allowed during programs. Cell phones will be collected by our staff and returned at the end of the program. ALL PRESCRIPTION MEDICATION MUST BE GIVEN TO ADVENTURELORE STAFF @ REGISTRATION. RECOMMENDED ITEMS: ___ Sleeping Bag / Pillow ___ Tent (1-2 person) ___ Flash Light ___ Mess Kit ___ Water Bottle/Canteen ___ Compass ___ Whistle ___ 2 pr. Sneakers or ___ 1 pr. Sneakers/1 pr. Hiking Boots ___ 1 pr. Warm Socks ___ Underwear & Socks (for length of trip) ___ Bathing Suits (2) ___ Beach Towels (2) ___ Water Shoes/sneaker/sandal type ___ Shorts/T-Shirts (for length of trip) ___ 2 pr. Jeans/Long Pants ___2 Sweat Shirts / Sweat Pants ___2 Poly Pro/Tek Wick T-Shirts (esp. XC & WM trips) ___ Rain Coat / Poncho ___ Bandanna ___ Hat (w/visor) PERSONAL ITEMS: ____Medications (staff will administer) ___ Soap, shampoo (biodegradable) ___ Toothbrush, toothpaste ___ Deodorant ___ Sun Screen (non-aerosol) ___ Insect Repellant (non-aerosol) ___ Comb, brush ___ Chapstick OPTIONAL ITEMS: ___ Disposable Camera ___ Sunglassses ___ Air Mattress/cushion ___ Ground Cloth ___ Trash Bag/Zip Lock bags ___ Swiss Army Knife (folding type) (acceptable on Senior Trips with staff knowledge) ITEMS NOT ALLOWED….knives, weapons, slingshots, fireworks, tobacco products of any kind, alcohol, drugs. ADVENTURELORE SUMMER PROGRAMS Acknowledgment of Risk and Liability Release Form Adventurelore is extremely proud of our safety record. We encourage parents and participants to discuss any safety concerns with us. We bring together a carefully selected, trained and experienced staff to provide quality programs. Safety is of paramount importance. However, despite our best capabilities, the possibility of an accident does exist and it is impossible to guarantee that injury will not occur. Therefore, as a condition of acceptance and participation in our program, we ask that you read and sign this form. In consideration of the services of Adventurelore Programs (including all counseling components), its agents, owners, officers, employees, sub-contracted members and all persons or entities acting in any capacity on its behalf, I agree to release and discharge Adventurelore on behalf of myself, my heirs, assigns, personal representative and estate as follows: 1. I understand and acknowledge the activity my child will engage in bears known and unanticipated risks that could result in injury, illness. disease, emotional distress, death. and/or damage to third parties. The following describe some, but not all risks of injury and/or damage as a result of hiking, canoeing, kayaking, sailing , water skiing, camping, bouldering, rock climbing, fishing, wrestling, trampoline use, ropes course, rappelling, bicycling, swimming, boating, white water rafting, games and activities. (Note: your child’s participation may not include all of these mentioned activities. In order to insure safety, we reserve the right to alter program formats due to weather and/or other unforeseen circumstances.) 2. I agree to accept all risks existing in our activities. My child’s participation is purely voluntary, not forced. 3. I agree to hold harmless, release, forever discharge and indemnify Adventurelore from any and all claims, demands, liability and/or actions that may occur with my child’s participation in activities including those allegedly attributed to the negligent acts or omissions of Adventurelore. 4. Should Adventurelore or anyone acting on its behalf be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and reimburse them for such fees and costs. 5. I certify my child has health, accident and liability insurance to cover any bodily injury or property damage caused while participating in your program. I agree to bear the costs of such damage or injury. 6. I fully understand and acknowledge this agreement includes but is not limited to any bodily injury or property damage that is sustained on or in connections with the use of any premises, property or real estate owned in whole or in part by Adventurelore. 7. By signing this document, I acknowledge that if anyone is hurt or property is damaged during my child’s participation in this program, I will have no right to make a claim or file a lawsuit against Adventurelore, its agents, owners, officers, employees, sub-contracted members, or any other person or entity acting in any capacity on its behalf even if they negligently cause such injury or damage. My signature indicates I have read, understand and agree to its terms. ____________________________________ Parent /Guardian Signature ________________________________ _______________ Print Name Date P.O. Box 395 197 Long Pond Rd. Danville, NH 03819 Phone (603) 382-4661 Fax (603) 382-0571 www.adventurelore.org Adventurelore Summer Program NAME: PROGRAM: ADDRESS: Phone: Cell: Work: Referred by: EMERGENCY CONTACTS: PERSONAL INFORMATION: Age: DOB: Height: Weight: **Please include a recent picture ** Hair color: Eye color: INFORMED CONSENTS: I hereby give consent and authorize, in case of an emergency, and in the event all reasonable attempts to contact me have been unsuccessful, for the administration of any X-ray examination, anesthesia, medical and surgical diagnosis and/or treatment, and hospital care deemed necessary by a licensed physician and supporting second-opinion licensed physician SIGNATURE of parent(s) or guardian(s): Pictures taken during our programs may or may not be used for advertising purposes. By signing this release, I authorize Adventurelore to use photos at their discretion on brochures,videos or website. SIGNATURE of parent(s) or guardian(s): MEDICAL INSURANCE INFORMATION: Insurance carrier: Policy number: Phone#: 1 Adventurelore Summer Registration Page 2 Primary Care Physician:____________________________Phone_______________________ Address__________________________________________________________________ Other physicians (if necessary): ____________________________Specialty__________________Phone_______________ ____________________________Specialty__________________Phone_______________ General Health: Excellent____ Good ____ Fair____ Date of most recent well check up___________________ Date of last tetanus___________ Eyeglasses Asthma Seizures Enuresis Allergies yes____ yes____ yes____ yes____ yes____ no____ no____ no____ no____ no____ Contact lenses Sleep Walking Nightmares Diabetes Migraine yes____ no____ yes____ no_____ yes____ no_____ yes____ no_____ yes____ no_____ ALLERGIES to medications: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Food Allergies: ___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Medications: Name: _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ Dosage: ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ 2 Reason for taking: _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Adventurelore Summer Registration Page 3 On this page, please note any pertinent information related to the physical, medical history or well being of this child. Please include any precautions for medications, any special arrangements or considerations you would like us to know. (This information may also be word-processed.) ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 3 Adventurelore Summer Registration Page 4 To help our staff become familiar with your child, kindly take a few moments and tell us, in your own words, about your child, his/her strengths and weaknesses, etc. Please be as candid and descriptive as possible, as the more informed we are about each and every child, the better prepared we can be to provide the ideal program experience. (This page may also be word- processed). ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 4