CAMP
In Partnership With
Camp I-VY 2015
Camper Registration Checklist
July 20th - 24th at Camp Huston in Gold Bar, WA
Camp I-Vy Registration Checklist:
Child Camper Registration Form / Health Form
Copy of Insurance Card
Check or Money Order for $50 per Camper*
*Financial assistance is available. Contact the BDFW
office to request a financial assistance form.
Registration Deadline is May 29th 2015
All completed forms can be returned to the BDFW at:
Email: [email protected] Fax: 206 533 1686
or
The BDFW
9639 Firdale Ave Ste A
Edmonds, WA 98020
Once we receive your camper application we will send you a registration receipt confirmation
form letting you know when we received your forms, whether or not they are complete, and the
order it was received in. The BDFW will review all camper applications up to the application
deadline of May 29th and reserves the right to decline any camper.
Camper acceptance letters will be sent in the first week of June. If you have any questions,
please do not hesitate to contact us anytime at [email protected] or 206 533 1660.
Camp I-VY 2015
CAMP
In Partnership With
Child Camper Registration Form (7-15 years old)
Health Forms Also Required
9639 Firdale Ave Ste A Edmonds, WA 98020
Camper’s Legal Name:!
Birth Date:
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City:
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Age:!
Address:! !
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(206) 533 1660
Gender:
Shirt Size: XS S M L XL Youth
M / F
Adult
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State:!
Zip:! !
Custodial Parent(s) / Guardian: ____________________________________________
Home Phone: ________________ Work Phone: ________________ Cell Phone: _________________
Address (if different from above): _______________________________________________________
City: ________________ State: ______ Zip: _____________ Email: ____________________________
Second Parent / Guardian (if applicable): ________________________________
Address: __________________________________________________ City: _____________________
State: _____ Zip: ____________ Cell Phone: ________________ Home Phone: __________________
If you will be away from home while your child is at camp please indicate where you can be reached:
Dates Away: ________________ Location: ________________________ Phone: __________________
Emergency Contact:
Name: ___________________________________ Relationship: ______________________________
Phone Number: _________________________ Alternate Phone: _____________________________
Transportation
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I will need assistance with transportation for my camper:
To Camp
From Camp
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I am willing to provide transportation for other campers to and from camp.
New Campers: Parents of first year campers must accompany their child to and from camp.
Social:
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Yes!
No
Has your child ever been away from home overnight?
Has your child been to an overnight camp before?
If yes, which camp & how many years? ________________________________________________
Has your child ever been involved in group activities (sports, youth group, etc.)
Does your child make friends easily?
Please provide any tips / insights you might have for setting your child up for success at camp:
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Please describe any concerns you have or information you feel would be useful to camp staff:
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Do you have any goals / hopes for your child during their time spent at Camp I-Vy?
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Camp I-VY Rules & Regulations
The following rules and regulations apply to all campers, counselors, counselors-in-training
(CIT’s), visitors and camp staff. The rules and regulations apply for the entirety of the camp
session. Please read them carefully and accept them by placing your signature where indicated.
A parent signature is also required for all campers and CITs under the age of 18. Failure to follow
these rules and regulations may result in being asked to leave Camp I-Vy.
1.
The possession or use of firearms, air guns, pellet guns, water guns, knives, slingshots,
other weapons, pornography, fireworks, illegal drugs, tobacco, marijuana or alcoholic
beverages is prohibited and will result in immediate expulsion. In addition, having
prescription drugs on your person without approval from the medical director will also be
grounds for immediate expulsion.
2.
In addition, possession of phones, radios, personal stereos, iPods, MP3 players,
keyboards or any other electronic device is prohibited. If found at camp, these items will
be held by the camp coordinator until the end of camp.
3.
All medication, prescription and over the counter, must be checked in at the Health Hut.
No medication my be kept with the camper unless cleared by the medical director.
4.
Respect the animals and plant life on the Camp Huston grounds and wherever camp
activities take place. Hike only on the designated hiking trails.
5.
For the health and safety of all campers, pets of any kind are not allowed on the Camp
Huston grounds, including during drop-off and pick-up time. This includes dogs.
6.
Outside food and beverages are not allowed at Camp I-Vy. Food and beverages are not
allowed at any time in the sleeping rooms or in the pool area.
7.
Rooms must be clean and in order at the end of camp. Report any broken equipment or
damage to camp property immediately to the camp director. Payment for damage beyond
normal wear and tear will be the responsibility of the parties involved.
8.
Closed toe shoes must be worn at all times. Flip-flops and open toe sandals are not
allowed except during pool times. Shirts and shoes must be worn at all mealtimes.
9.
Immediately report bleeds, cuts, scrapes and other injuries requiring medical attention to
the Health Hut staff.
10. Camper, counselors and camp staff must treat each other with respect at all times.
Profanity is not allowed at Camp I-Vy and everyone’s privacy must be respected.
11. All campers are to be in their assigned cabins with the lights out and quiet between their
assigned lights out time and 6:00am. All staff must be in their cabins by 12:00 midnight.
I, ___________________________________________ (Please Print), accept the above rules and
regulations and agree to follow them at all times while at Camp I-Vy.
Camper Signature:!!
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I, ____________________________________________ (Parent Name), have read and discussed
the above rules and regulations with my child attending Camp I-Vy.
Parent/Guardian Signature:!
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General Authorization Release:
Parent’s Authorization: I, the undersigned parent/person having legal custody/guardianship of ____________________
(Camper Name), hereby give permission of the minor to participate in the camping programs of Camp Huston. I give
permission for individual or group photographs or video footage of my child to be used by the camp and the Bleeding Disorder
Foundation of Washington for historical and/or promotional purposes. I understand that the camp program includes such
activities as long hikes, sleeping outside in tents, cooking around a campfire and group discussions. The minor is physically
able and mentally prepared to participate in all camp activities. I hereby voluntarily and knowingly assume all risks and
dangers inherent and incidental to the activities of the camp program. I will not hold Camp Huston, the Dioceses of Olympia,
Inc., or the Bleeding Disorder Foundation of Washington liable for any injuries incurred during the program whether caused by
equipment or the acts of omission of others excepting damage or injury solely caused by the willful misconduct or negligence
of Camp Huston, the Bleeding Disorder Foundation of Washington or their employees or agents.
Parent/Guardian Signature:!
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Camper Agreement: I have read the letter for my session at Camp Huston and I am looking forward to my stay. I am willing
and able to participate fully in all camp activities. I will do my best to work with others, to respect the property of Camp Huston,
other campers, and the camp staff. I understand that failure to live up to this agreement might result in early dismissal from
Camp I-Vy without a refund.
Camper Signature:!!
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Photo Policy & Release:
From time to time the Bleeding Disorder Foundation of Washington (BDFW) will want to use pictures or videos taken from
camp to promote Camp I-Vy and other BDFW programs. We would like permission to use your child’s image for that purpose.
I hereby give my permission for the BDFW to use my child’s image, in print or video, in anyway seen fit by the Bleeding
Disorder Foundation of Washington. I acknowledge that due to the sensitive nature of Camp I-Vy any photos I or my
child may take with their camera while at Camp I-Vy will not be posted on an public or social media websites such as
Facebook, Instagram, Twitter, etc.
Parent/Guardian Signature:!
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Camper Behavior Policy:
I understand that if my child’s behavior is in violation of Camp Huston rules, or my child is deemed harmful to the camp
community, my child may be sent home from camp and I will be responsible to pick my child up from Camp Huston. I
acknowledge that I may be held financially responsible for acts of vandalism caused by my child. I have read and I understand
the Camp I-Vy Behavioral Contract that accompanies this camp application. Camp Huston and The Bleeding Disorder
Foundation of Washington are not responsible for the loss of, damage to, or theft of my child’s property.
Parent/Guardian Signature:!
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Camper Signature:!!
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If your child is requested to leave camp due to a violation of the camp rules, you must designate an alternative pick up person
in the event you are unable to be reached.
Alternative Contact: _____________________________ Phone: ____________________________
Please return completed forms to:
CAMP
The Bleeding Disorder Foundation of Washington
9639 Firdale Ave Ste A
Edmonds, WA 98020
Registration Deadline is May 29th, 2015
2015
Factor Product Used: ______________________________________
Camper
Health Form
Camper Weight: __________________ lbs / kg
Hematologist / HTC: _______________________________________
Emergency Contact:
Name: __________________________________ Relationship: ______________________________
Phone Number: _________________________ Alternate Phone: ____________________________
Bleeding Disorder Information:
Hemophilia:!
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Hemophilia A:!
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Hemophilia B:!
Severity:
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Mild: !
Moderate:!
Severe:
von Willebrand Disease:
Type 1:!
Type 2A:! !
Type 2B:!
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Type 2N: ! !
Type 3:
Other Bleeding Disorder / Factor Deficiency: ____________________________________________
Inhibitor:
Has the camper ever had an inhibitor? No:
Carrier Status: ! Carrier:!
Yes, Currently:
Non-carrier: !
Yes, Dates: ________________
Untested:!
No Bleeding Disorder / Sibling:
Prophylaxis:
Camper is on a prophylaxis regiment? ! Yes:
No: !
If yes, prophylaxis schedule while at camp (please circle):
N/A:
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Tues
Wed
Thurs
Fri
Notes: ___________________________________________________________________________
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Does the camper have a target joint? If so, please describe: ______________________________
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Medical Forms Page 1/6
2015
Camper
Health Form
Have questions about these forms?
Contact BDFW office at 206 533 1660 or [email protected]
Please be sure to include a copy of your insurance card.
Copy both sides so that all information is readable.
Medical Forms Page 2/6
2015 Camper Health Form
Camp I-Vy Health Forms - 2015
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2015 Camper Health Form
Camp I-Vy Health Forms - 2015
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2015 Camper Health Form
THE FOLLOWING MUST BE COMPLETED
Unless this form is signed by a parent or guardian the camp
cannot get emergency treatment for your child in case of
emergency. Thank you for your cooperation.
AUTHORIZATION TO CONSENT TO TREATMENT OF MINOR
PARENT’S AUTHORIZATION: This Health History is correct so far as I know and
__________________________ (camper’s name) herein described has permission to engage
in all described camp activities except as noted by me and the examining physician. I hereby
give permission to the medical personnel selected by the camp director to provide routine
health care; to dispense medications and to seek emergency medical treatment; to order Xrays, routine tests, treatment; to release any records necessary for insurance purposes; and to
provide or arrange necessary related transportation for me/or my child. In the event I cannot be
reached in an emergency, I hereby give permission to the physician selected by the camp
director to secure and administer treatment, including hospitalization, for the person named
above. This completed form may be photocopied for trips out of camp.
Parent/Guardian Signature:!
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Infusion Training / Treatment Discussion Consent: The Medical Staff at Camp I-Vy will be
offering self-infusion instruction to campers on a voluntary, informal and individual basis by
trained professionals. Your child could receive training when they need treatment during Camp
I-Vy, but only if the child is voluntarily ready to infuse themselves. In addition, other bleeding
disorder related treatments & procedures may be discussed with your camper as appropriate.
I hereby consent to have my child receive self-infusion training at Camp I-Vy.
Parent/Guardian Signature:!
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Factor Usage Consent: I understand that I am responsible for supplying an adequate amount
of factor for my child for the week of camp. I understand that every effort will be made to give
my child only their designated factor. However, I realize that the possibility exists that a medical
emergency may require my child to use additional factor, which will be charged to my
insurance. If this situation occurs, I understand that the Camp I-Vy Medical Staff will authorize
the appropriate factor usage, which will be fully documented in my child’s medical log.
Parent/Guardian Signature:!
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If your child is due to receive a factor infusion on Monday, the first day
of camp, please be sure to infuse at home before arrival at Camp I-Vy.
Parents/Guardians: STOP here.
The rest of this form is completed when the camper arrives at camp. Keep a copy for your records.
Camp I-Vy Health Forms - 2015
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2015 Camper Health Form
Camp I-Vy Health Forms - 2015
Medical Forms Page 6/6
IT’S THAT TIME OF YEAR
AGAIN! TIME TO SIGN UP
YOUR TEAM!
Join us for the 3rd annual Bloody Fun Run
& Walk!
!
Last year was incredible, raising over
$100,000! The community came out in
force (and in their best costumes) to spread
awareness for bleeding disorders. We can’t
wait to see what happens this year!
!
To register your team, or join another, go
to:
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WALK.BDFWA.ORG
What:
3rd Annual Bloody Fun Run & Walk
When: Saturday, October 24th
Where: Green Lake Park
7312 West Green Lake Dr N
Seattle, WA 98103
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Questions? Email us at [email protected]