Camp UKANDU Survivor Packet
Dear Parents and Campers:
Get ready! We are gearing up for another outrageously fun summer at Camp UKANDU! We are excited
for the opportunity to have your child join us!
For each camper, please review and carefully complete the designated registration forms- there are
separate packets for the “survivor” and for the “sibling”. The full application includes detailed medical
information, and requires a doctor’s signature for a childhood cancer survivor and a notarized
Authorization for Treatment form (for both the childhood cancer survivor & sibling).
Camp UKANDU will be held from Sunday, June 21st through Saturday, June 27th, 2015 at beautiful YMCA
Camp Collins, in Gresham, OR. For more information on YMCA Camp Collins, please visit their website
at: www.campcollins.org.
Please return the application(s) in their entirety, to the address listed below, no later than Friday, May
8th, 2015 – but the earlier the better! Parents will be contacted when applications are incomplete.
Camp UKANDU
601 SW 2nd, Suite 2300
Portland, OR 97204
Informational (acceptance) forms will be sent to all eligible campers, after receiving your child’s
completed application. If you have any questions about camp, please contact Haelynne Barron at 503276-2178 or e-mail [email protected].
Happy Camping,
Haelynne “Zuma” Barron
Director
Camp UKANDU
More information about Camp UKANDU can be found at www.campUKANDU.org
1
Camp UKANDU and the American Camp Association
Camp UKANDU is an American Camp Association (ACA) - Accredited Camp. What does that mean for
your child?
American Camp Association (ACA) accreditation means that Camp UKANDU submitted to a thorough
(over 300 standards) review of its operation by the ACA — from staff qualifications and training to
emergency management — and complied with the highest standards in the industry.
As parents, you expect your child to attend accredited schools. Your child also deserves a camp
experience that is reviewed and accredited by an expert, independent organization.
Camp UKANDU and ACA have formed a partnership that promotes summers of growth and fun in an
environment committed to safety. By attaining ACA accreditation, Camp UKANDU has demonstrated its
commitment to quality camp programming.
ACA is the only independent accrediting organization reviewing camp operations in the country. Its
nationally recognized standards program focuses primarily on the program quality, health and safety
aspects of a camp's operation. ACA collaborates with experts from The American Academy of Pediatrics,
the American Red Cross, and other youth service agencies to assure that current practices at the camp
reflect the most up-to-date, research-based standards in camp operation. For more parent-focused
information about accreditation, visit ACA's www.CampParents.org.
2
CAMP UKANDU RESIDENTIAL CAMPING PROGRAM
MISSION STATEMENT
The mission of Camp UKANDU is to bring joy and hope to children living with cancer, their siblings and their
families through “outrageously fun” camping experiences.
PHILOSOPHY
The purpose of Camp UKANDU is to offer a planned week of camping activities designed for children age 8 through
18 (or senior year of high school) living with cancer (patients and siblings). It provides opportunities for outdoor
play, socialization with other children in similar circumstances, and the explorations and use of individual talents
and strengths- all with careful supervision by medical specialists and trained adult volunteers. There are no set
“standards of achievement”; each child is accepted as a unique individual and is encouraged to participate at a
level comfortable to them. Helping each child feel safe and secure is a top priority. Camp UKANDU recognizes the
“long-term” survivor and helps children prepare to move into other camping experiences.
RESIDENTIAL PROGRAM GOALS, OUTCOME OBJECTIVES AND IMPLEMENTATION AT CAMP:
Goal 1: To provide campers with a safe, well-staffed camping environment.
Outcome Objectives:
100% of the time, all campers will be supervised in a 5:1 camper to staff ratio.
Train all staff.
Goal 2: To provide medical expertise and close monitoring required by children with cancer and not offered at
ordinary summer camps.
Outcome Objectives:
100% of the campers will be monitored by at least two oncology nurses and one pediatric oncology
physician.
Goal 3: To welcome any child well enough to enjoy the experience and who can safely attend camp.
Outcome Objectives:
100% of all participants are identified by their doctors to be well enough to attend camp.
Goal 4: To give all children the opportunity to attend camp without financial cost to their families.
Outcome Objectives:
100% of all participants may attend any Camp UKANDU program at no cost.
Goal 5: To help give parents whose children attend camp assurance by running a safe, secure program, and
providing them with all necessary information and support.
Outcome Objectives:
100% of families receive Camp UKANDU informational packets at least 2 weeks prior to Camp
UKANDU program.
100% of families will have received written documentations regarding camp accreditation,
association and information on medical care and programs.
3
Eligibility Guidelines for Camp UKANDU 2015 - Survivor
Children who have a diagnosis of cancer, who have had a bone marrow transplantation (BMT), or a stem
cell transplantation (SCT), along with one brother or sister, who are between the ages of 8 and 18
(eligibility ends at the age of 18 and/or high school graduation) AND who come under one of the
following:






Child diagnosed with cancer on active cancer therapy.
Child diagnosed with cancer off therapy for less than three years (as of June 21, 2015.)
Child less than two years (as of June 21, 2015) from date of BMT/ SCT or end of
Immunosuppressive therapy.
Child who completed cancer therapy, BMT/SCT prior to the age of 8. (Eligible to
attend camp for three years.)
Child who has had cancer, who is currently not on treatment and has not attended
camp for the three years they are eligible.
If your child(ren) does not meet the above criteria but would like to be considered and on a
waiting list, please check here. NOTE: Those applicants on the waiting list will have their information
reviewed by the Camp UKANDU Medical Committee and Camp Director to assess for greatest need.
Decisions will also take into account available space. It will be to their full discretion to make a final
decision. You will be contacted by Friday, May 29, 2015 if your child has been selected to attend.
You may apply to be on the waiting list for one year.
Please remember:
 Space is limited and will be assigned on a priority basis according to the list above.
 Returning campers should submit their applications as soon as possible to secure a spot at
Camp UKANDU.
 A designated number of spaces will be held for children newly diagnosed.
Please contact Haelynne Barron with any questions: [email protected] or 503.276.2178.
Please return application (including this page) to:
Camp UKANDU
601 SW 2nd Ave, Suite 2300
Portland, OR 97204
4
2015 Camp UKANDU Registration Packet Information
Child with Cancer Registration Packet
This packet contains important forms that must accompany your child’s registration form and be
completed in full, signed, and returned to the camp office in order for your child to be eligible to attend
Camp UKANDU.
If you have more than one child attending Camp UKANDU, please complete the Sibling Registration
Packet as well. Each camper needs a complete registration packet with their name and information only.
You must include a copy of the front AND back of your child’s medical insurance card. Please attach it to
the Health Insurance Form (page 14).
These forms must be signed and returned to Camp UKANDU no later than Friday, May 8th, 2015.
Please return these forms to:
Camp UKANDU
601 SW 2nd, Suite 2300
Portland, OR 97204
Questions?
Contact Haelynne Barron at 503.276.2178 or [email protected]
5
2015 Camp UKANDU Registration Form
Child with Cancer Registration Packet
*Please include a current, close up, photo of your child.
This photo will be kept with our camper files and will be used by our
Medical staff and management team to quickly and easily identify your child.
Child’s Full Name: ________________________________________________________________
First
Middle
Last
Gender: Male:_____ Female:______ Date of birth: ___________ Age: ______Grade: _________
Ethnicity (optional): _______________ Sweatshirt size: Youth: S M L
Adult: S M L XL
Address: _______________________________________________________________________
Street
City
State
Zip
County
Has the child attended camp before? Yes______ No ______ If yes, what year(s)? ______________
Name of Parent/Legal Guardian: ______________________________________________
Home phone: ___________________ Email address: ____________________________________
Cell phone: _________________________Work Phone: __________________________________
Name of Parent/Legal Guardian: ______________________________________________
Home phone: ___________________ Email address: ____________________________________
Cell phone: _________________________Work Phone: __________________________________
*Please indicate preferred method to be reached (Email, Home #, Cell #, Work #)
Your child’s type of cancer: _________________________________________________________
Date of cancer diagnosis: __________________________________________________________
Month & Year
Is your child still receiving cancer treatment?
(Chemotherapy, Radiation, Bone Marrow Transplant, Stem Cell Transplant): Yes______ No_____
When was your child’s therapy discontinued, if applicable? _______________________________
Month & Year
Is there an eligible sibling that will be attending Camp UKANDU? Yes ___________ No __________
Has this sibling attended camp before?: Yes________ No _______ If yes, what year(s)? ________
Sibling’s name: __________________________________________________________________
** If a sibling is eligible and plans to attend, please complete a seperate Sibling Registration Packet.
6
2015 Camp UKANDU Medical Form
Child with Cancer Registration Packet
TO BE COMPLETED BY PARENT/GUARDIAN
Camper’s Name: ______________________________________________________________________
Oncologist Name: ___________________________ Phone: ___________________________________
Treatment Center: Randall @ Legacy Emanuel _____ Doernbecher @ OHSU _____ Other: __________
Dentist Office: _____________________________________ Phone: _____________________________
Please check below if your child will have one of the following in place during camp:
__________ Hickman/Broviac
__________ Groshong
__________ Port
Don't forget to send along needed catheter care supplies!
Camp policy does NOT allow swimming for campers with Broviac/Hickman catheters. Patients with a Port may swim
unless accessed within previous day.
Answers to the following questions are REQUIRED to be eligible.
ALLERGIES
Allergies to any food:___________________________________________________________
Hay Fever:___________________
Plants (type): _______________________________________
Insect Stings (type):____________
Medication(s) you are allergic to:__________________________
Other:___________________
When an allergic reaction occurs, what happens?_______________________________________
_______________________________________________________________________________
What do you do in an allergic reaction situation?_______________________________________
_______________________________________________________________________________
IMMUNIZATION
Please give all dates of immunizations
Vaccine
Dates: Mo/Yr
Tetanus (most recent)
__________
OTHER ACTIVITIES
Any restrictions on activity level? Yes____ No____ If “YES”, please explain ________________________
_____________________________________________________________________________________
Any dietary modifications? Yes____ No____ If “YES”, please explain _____________________________
_____________________________________________________________________________________
What are some food suggestions? __________________________________
Can your child swim without assistance? (Not without supervision) Yes ______No ______
7
2015 Camp UKANDU Health History Form
Child with Cancer Registration Packet
HEALTH HISTORY – Pg. 1
Camper’s Full Name: ___________________________________
Condition
Condition
Diseases
Ear Infection ___
Heart Disease ___
Convulsions ___
Diabetes
___
Bleeding disorder ___
Constipation ___
Diarrhea
___
Ostomy
___
Bedwetting
___
Sleepwaking ___
Prosthesis
___
Headaches
___
Skin Problem ___
Asthma
___
Chicken Pox __
Measles
__
Chronic or recurring
illness/condition
other than cancer ___
Please explain any boxes checked:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SPECIAL ACTIVITIES-OF-DAILY-LIVING NEEDS
Indicate with a “YES” if any assistance is needed by your child and explain.
Yes____
Yes____
Yes____
Yes____
Yes____
Yes ____
Yes ____
Dressing:______________________________________________________________
Eating:________________________________________________________________
Toileting:______________________________________________________________
Walking from place to place (Balance/Endurance): ____________________________
Needs wheelchair Assistance (Describe):_____________________________________
Have an orthopedic appliance being brought to camp: _________________________
Have glasses and/or protective eye wear: ___________________________________
For Female Campers:
Has child ever menstruated? Yes_____ No_____
If not, has she been told about it? Yes ______ No _______
If yes, is her menstrual history normal? Yes _______ No _______
Any special considerations we should know about? ________________________________________
8
2015 Camp UKANDU Health History Form
Child with Cancer Registration Packet
HEALTH HISTORY – Pg. 2
Camper’s Name: ___________________________________
MENTAL, EMOTIONAL, AND SOCIAL HEALTH
Has the camper:
1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder
(AD/HD)?
Yes____ No____ If “YES”, please explain ________________________________________________
_________________________________________________________________________________
2. During the past 12 months, have there been mental/emotional health concerns?
Yes____ No____ If “YES”, please explain ________________________________________________
________________________________________________________________________________
3. Had a significant life event that continues to affect the camper’s life? (history of abuse, death of
loved one, family change, adoption, foster care, new sibling, surviving a disaster, other)
Yes____ No____ If “YES”, please explain ________________________________________________
_________________________________________________________________________________
EXPOSURE
*Important: Please notify Camp UKANDU if camper is exposed to chicken pox, lice or any
infectious disease within three weeks prior to camp attendance. We will be administering lice
checks upon camper arrival. Should your camper be found to have lice, they will be not be allowed
to attend camp until they have been treated at home and checked by medical staff at camp. If you
have question regarding this policy, please contact the camp office.
Camp policy is that camp doctors or nurses must give all medication. All medications to be given at
camp, including over the counter and vitamins, must be presented to a camp nurse when checking
in at registration. All medications must come in their original bottles with labels showing complete
directions for administration and the camper’s name is prescribed.
REMEMBER: DO NOT PACK MEDICATION IN CAMPER'S LUGGAGE!!
9
2015 Camp UKANDU Health History Form
Child with Cancer Registration Packet
HEALTH HISTORY – Pg. 3
Camper’s Name: ___________________________________
If you DO NOT WANT your child to receive any of the “as needed” medications below while at camp,
please initial here: ___________
Otherwise, a doctor or nurse may give as needed.
Please CROSS OUT any of the below medications that your child should NOT receive.
The following list of medications for headaches, colds, bumps, sunburns and scratches are stocked
at camp in the Med Hut:
- Acetaminophen (Tylenol®)
- Ibuprofen (Advil®, Motrin®)
- Diphenhydramine (Benadryl®)
- Sudafed®
- Cough Syrups
- Throat lozenges
- Sunscreen
___________________________________________________________________________________
Parent/Guardian's Name (Please Print)
___________________________________________________________________________________
Parent/Guardian's Signature/Date
10
2015 Camp UKANDU Health Insurance Information Form
Child with Cancer Registration Packet
(One form per child, please.)
Child’s First Name: _________________________ Child’s Last Name: ____________________________
My child has medical insurance________ My child does NOT have medical insurance _______
Primary Physicians Name: _______________ Clinic: _______________ Phone: ____________________
Insurance Company: ______________________________ Policy #: _____________________________
Unless your child does not have insurance, we must have a copy of your child’s medical insurance card
in order for him/her to be eligible to attend camp.
*Please staple a copy to this form - (please copy front & back of card)
ONLY COMPLETE THIS NEXT SECTION OF THIS PAGE IF YOUR CHILD IS NOT COVERED BY MEDICAL
INSURANCE.
I hereby acknowledge that my child or ward, __________________________ (Name of camp
participant, herein after referred to a “Camp Participant”) is not currently covered by medical insurance.
As the parent or guardian of “Camp Participant”, I agree to and understand that I am solely responsible
for any and all costs for medical services and/or and transportation costs incurred during the time that
“Camp Participant” attends Camp UKANDU.
I also agree to and understand that neither the YMCA of Columbia-Willamette, Camp UKANDU, nor its
employees, agents or volunteers assume any liability whatsoever for any medical services and costs and
/or transportation costs incurred by “Camp Participant” during his or her participation at Camp
UKANDU. I do hereby agree to indemnify and hold harmless Camp UKANDU and any Camp UKANDU
employee, agent, volunteer or designated chaperone and the YMCA of Columbia-Willamette, and YMCA
Camp Collins from any and all liability, damage, loss, claims or demands and actions of any nature
whatsoever, including attorneys’ fees, which arise out of or are in any way connected with the provision
of such emergency medical services.
___________________________________________________________________________________
Parent/Guardian's Name (Please Print)
Parent/Guardian's Signature/Date
11
Camp Ukandu SAMPLE Medication Form
Camper’s Name:
Medication
Methotrexate 2.5 mg take
12 tablets at bedtime on
Friday
Mercaptopurine 50 mg
Take 2 ½ tablets every day
at bedtime
Oxycontin 5 mg take 1
tablet every 6 hours
Zofran 8 mg every 8 hours
as needed for nausea
Albuterol inhaler 2 puffs
every 4 hours as needed
for asthma
Vitamin D 1 tablet (500 )
once a day every morning
Calcium 200 mg 3 times a
day with meals
Janice Star Litman
Frequency
BF
Lunch
Dinner
Bed
BF
Lunch
Dinner
Bed
BF
Lunch
Dinner
Bed
BF
Lunch
Dinner
Bed
BF
Lunch
Dinner
Bed
BF
Lunch
Dinner
Bed
BF
Lunch
Dinner
Bed
Time
Sun
Mon
Tue
Wed
Thur
Fri
Sat
X
X
0600
1200
1800
2400
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Sample Only
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
12
Camper’s Name: _____________________________
2015 Camp UKANDU Medication Schedule Form
Child with Cancer Registration Packet
If your child is no longer on treatment or taking any medication, please initial here________.
*Please include ALL prescription meds, herbal supplements, and vitamins.
Medication
Frequency
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Breakfast
Lunch
Dinner
Bedtime
Time Sun
Mon
Tue
Wed
Thur
Fri
Sat
1.) Are there any special routines when medications are given? Yes______ No_______
Please describe: ______________________________________________________________________
2.) Are there any special foods or liquids given with medications? Yes_____ No____
Please describe: ______________________________________________________________________
13
2015 Camp UKANDU Authorization For Treatment
Child with Cancer Registration Packet
(One form per child, please.)
YOU MUST RETURN THIS FORM WITH A NOTARY SIGNATURE AND SEAL OR YOUR CHILD WILL NOT BE
PERMITTED TO STAY AT CAMP. YOU MUST SIGN IN THE PRESENCE OF A NOTARY!
In consideration of this camping opportunity, applicant does thereby agree to indemnify and hold Camp
UKANDU and the YMCA of Columbia-Willamette, and YMCA Camp Collins harmless from any claims for
accident or injury sustained by the camper named in this form while attending or participating in any
Camp UKANDU program on or off the YMCA of Columbia-Willamette – Camp Collins premises.
I further consent to any routine or non-surgical medical care that my child may be required to have
either due to circumstances previous or during the camp session.
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by
the individual in charge to hospitalize, secure proper treatment for and to order injection, anesthesia, or
surgery for my child as named below. Your signature is required or we will not be able to accept your
child at camp. In case of emergency, we will make every effort to contact parent/legal guardian, and/or
designee.
Emergency number of parent/legal guardian:
Name: _________________________________ Emergency Number: ____________________________
Designated emergency contact person:
Name: _________________________________ Emergency Number: ____________________________
Relationship: _________________________________________________________________________
Print Camper’s Name: __________________________________________________________________
Print Parent or Legal Guardian’s Name: ____________________________________________________
To be signed in presence of notary
Signature of Parent or Legal Guardian: ____________________________________________________
TO BE IN EFFECT, THIS FORM MUST BE NOTARIZED BELOW.
******************************************************************************
State of _____________________________________
County of ___________________________________
On ___________________________, 2015, _________________________________________
personally appeared before me,
_____ who is personally known to me
_____ whose identity I proved on the basis of ___________________________________________
_____ whose identity I proved on the oath/affirmation __________________________ a credible
witness, to be the signer of the above document and he/she acknowledged that he/she signed it.
Notary Signature: __________________________________________________________
My Commission Expires: _____________________________________________________
14
2015 Camp UKANDU Authorization to Disclose Medical Information
Child with Cancer Registration Packet
AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION
This form must be dated and signed by the person authorized by law to give this consent.
I authorize __________________________________________________________________________
Name of Hospital Facility Providing Oncology Services
to release a copy of the medical information to Camp UKANDU located at 601 SW 2nd, Suite 2300
Portland, OR 97204.
___________________________________________________________________________________
Name of Patient
The information will be used to safely manage the health care of my child while attending Camp
UKANDU.
I specifically authorize the release of the following medical records, if such records exist:
 Medical History
 Medical records needed for continuity of care
 Information about the diagnosis and medical management of my child’s condition
 List of current medications and any allergies to medications
 Recent lab reports
This information will be provided for use by the medical staff (physicians and nurses) at Camp UKANDU.
This information may also be provided to the staff at an emergency care center during the week of
attendance at the camp if the situation should arise.
This authorization may be revoked at any time. However, authorization must be active to allow
participation of the child at Camp UKANDU. This consent will expire following the completion of Camp
UKANDU 2015.
_________________________________________________________ __________________________
Signature of person authorized by law
Date
____________________________________________________________________________________
Relationship to patient
15
2015 Camp UKANDU Parent/Guardian Letter
Child with Cancer Registration Packet
A Letter to My Camper’s Counselors
CAMPER’S NAME:___________________________
MY NAME: ________________________
_ AGE ___________
_ RELATION TO CAMPER: ____ _________
This is my camper’s
year at an overnight summer camp and
I want them to go to camp because
year at Camp UKANDU.
While at camp I hope they will
I think they will naturally thrive at
I think they may need extra support to succeed at
My camper is a:
strong swimmer
fair swimmer
doesn’t know how to swim
When talking about camp:
-my camper is most excited about
-my camper is most nervous about
My camper is:
-most happy when
-most unhappy when
-enthusiastic about
-afraid of
-good at
-working on
If my camper were to miss home, I would suggest
My camper has been diagnosed as having some special needs such as learning disabilities, emotional or
behavioral considerations:
No
Yes and staff can best support them by:
16
2015 Camp UKANDU Parent/Guardian Letter
Child with Cancer Registration Packet
CAMPER’S NAME:___________________________
My camper functions:
-Mentally
below
at
-Emotionally
below
at
-Physically
below
at
Please feel free to elaborate
_
above - their age level
above - their age level
above - their age level
The things their friends enjoy most about them are
I hope to see my camper grow in:
If my camper were to get tired, frustrated, distracted, etc… I would suggest
What is your camper’s routine for going to bed each night? (bathing, reading, night light, etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional comments/suggestions/helpful hints:
17
2015 Camp UKANDU Camper Letter
Survivor Registration Packet
A Letter to My Counselors
My name is :___________________________ _ My friends call me:
When I come to camp I will be
years old.
This is my
time at a sleep-away summer camp and
time at Camp UKANDU.
I think I am good at
Some things I like to do with my friends for fun are
Some things I like to do by myself for fun are
I want to go to camp because
While at camp I hope to
I am an only child:
If NO: I have
My
they are
YES
NO
sisters. I have
brothers.
(sister or brother) is at camp too, and their name is
years old.
and
When I am not happy, I usually feel
and others can help me by
I get along with friends who
I would like to have a counselor who
Anything else you would like to tell your counselors:
18
2015 Camp UKANDU Camper Participation Consent Form
Child with Cancer Registration Packet
I hereby request and consent that my child or ward,________________________________, be
permitted to participate in: CAMP UKANDU on the following dates: June 21 – June 27, 2015.
I agree to and understand the following:
 My child or ward may be accompanied and transported by Camp UKANDU officials however, neither
the YMCA of Columbia-Willamette, YMCA Camp Collins, nor its employees, agents, or volunteers,
assume any liability whatsoever by such accompaniment or transportation.

I agree that neither Camp UKANDU, its employees, agents, or volunteers associated with Camp
UKANDU shall be held responsible for any injuries or damages that occur during the time my child is
in attendance at or is participating in Camp UKANDU. I do hereby hold harmless Camp UKANDU, its
employees, agents, and volunteers, the YMCA of Columbia-Willamette, and YMCA Camp Collins
against any and all liability, damage, loss, claims or demands which arise out of or are in any way
connected with my child or ward’s attendance at or participation in Camp UKANDU.

I hereby authorize any Camp UKANDU employee, agent, volunteer, or designated chaperone to
consent to emergency medical treatment as necessary for the health and safety of my child or ward.
I further agree that no Camp UKANDU employee, agent, volunteer, or designated chaperone will be
held responsible for injuries or damages arising from the provision of any such emergency medical
treatment. I also authorize the treating medical institution and/or medical providers to hospitalize
and administer the appropriate treatment deemed medically necessary for my child. I do hereby
agree to indemnify and hold harmless Camp UKANDU and any Camp UKANDU employee, agent,
volunteer, or designated chaperone and the YMCA of Columbia-Willamette, and YMCA Camp Collins
from any and all liability, damage, loss, claims, or demands and actions of any nature whatsoever,
including attorneys’ fees, which arise out of or are in any way connected with the provision of such
emergency medical services.

I grant permission for my child or ward to appear in person or in voice, video or photographic
presentation for radio, television, print, or media campaign(s) resulting from participation at Camp
UKANDU.
The nature of the Camp UKANDU Camper Consent Form has been reviewed by me, and I hereby give my
approval.
I have read this document, I understand its contents, and I agree to its terms.
________________________________________________________ ____________________
Participant Name
Date
________________________________________________________ ____________________
Parent/Guardian Signature
Date
________________________________________________________
Parent/Guardian Name Printed
19
2015 Camp UKANDU Camper Behavior Expectations
Child with Cancer Registration Packet








We expect that all campers come to Camp UKANDU because they want to participate in a camp
experience.
We expect that all campers are willing to participate in group activities and will cooperate with
other children and adults.
We expect that all campers will behave in such a manner that they will not disrupt nor interfere
with other children's enjoyment.
We expect that all campers will use appropriate language.
We expect that all campers will not act in such a way to threaten or cause injury to themselves
or others.
We expect all campers to help ensure the safety of themselves and others by leaving
knives/firearms/weapons of any kind at home.
We expect that all campers will have a smoke, alcohol and drug free experience at camp.
We expect that all campers will not engage in sexual behavior while at camp.
STEPS IN PROBLEM SOLVING
The camper’s individual counselors will first deal with problems. If the problem continues, the
counselors will consult with the Camp Director, the Rainbow Connection support staff, or other mental
health professionals. The camper will be involved and made aware of the concern, and a plan will be
developed to help the camper meet Camp UKANDU's behavior expectations. If the problem continues,
the parents/guardians will be contacted asking for their suggestions, and advising them of the concern.
Finally, if the camper continues to behave in a disruptive manner, or is apparently so unhappy that
he/she does not wish to stay at camp, the parents/guardians will be asked to take the camper home as
soon as possible.
If you (the parents/guardians) anticipate that your child may have behavioral issues at camp, please
inform the Camp Director, so a plan can be put into place before camp. (Call Hillary Orr at
503.276.2178.)
In the rare event of a severe behavior issue or problem, you will be contacted immediately and required
to remove your child from camp immediately.
I understand both the behavior expectations and the procedures of problem solving for my child/myself
at camp.
_______________________________________
Parent Signature
__________________________________________
Camper Signature
Camper Commitment: (signature required) I want to become a camper at Camp UKANDU. I will do my
best to follow instructions, remain is designated areas, and keep others and myself safe. I will do my
best to make this a good experience for my fellow campers and myself. I understand that failure to live
up to this promise might result in my dismissal from camp.
_______________________________________
Camper Signature
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2015 Camp UKANDU Adult Authorization for Pick-up
Child with Cancer Registration Packet
(One form per child, please.)
Campers must be picked up from Camp Collins on Saturday, June 27th, 2015 by 11:30 am. Camper will
ONLY be released to adults identified below. Authorized adults will be required to show valid ID upon
pick-up.
My Child (name), _____________________________________________________________________ ,
will be picked up by 11:30 am from Camp UKANDU at YMCA Camp Collins by one of the following:
Name (as it appears on ID): ___________________________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
City
State
Zip
Phone Number(s): __________________________________________________________________
Relationship to Camper: _____________________________________________________________
Name (as it appears on ID): ___________________________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
City
State
Zip
Phone Number(s): __________________________________________________________________
Relationship to Camper: _____________________________________________________________
Name (as it appears on ID): ___________________________________________________________
Address: __________________________________________________________________________
__________________________________________________________________________________
City
State
Zip
Phone Number(s): __________________________________________________________________
Relationship to Camper: _____________________________________________________________
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2015 Camp UKANDU Adult Authorization for Pick-up
Child with Cancer Registration Packet
Pg. 2
NOTE: FOR THE SAFETY OF YOUR CHILD, ONLY THE PERSONS DESIGNATED ON THIS FORM TO PICK UP
YOUR CHILD, WILL BE ALLOWED TO LEAVE CAMP WITH YOUR CHILD. IF A CHANGE NEEDS TO OCCUR,
BE IN TOUCH WITH THE CAMP DIRECTOR PRIOR TO CAMP, TO MAKE ALTERNATE ARRANGEMENTS.
YOU WILL BE EXPECTED TO SHOW PHOTO ID UPON PICK UP OF YOUR CHILD.
IF YOUR CHILD HAS NOT BEEN PICKED UP FROM, AND/OR DOES NOT ARRIVE AT CAMP UKANDU BY
HIS OR HER EXPECTED TIME, THE LISTED LEGAL GUARDIAN(S) WILL BE CONTACTED IMMEDIATELY, BY
THE CAMP UKANDU DIRECTOR, OR CAMP UKANDU LEADERSHIP VOLUNTEER. A VOICEMAIL MAY BE
LEFT, WITH QUESTIONS AND FURTHER INSTRUCTION.
THANK YOU! 
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Agreement to Participate
Programmed Activities
YMCA CAMP COLLINS
Participants Name: _____________________________________Birth Date: _____________________Age: _______________
Address:__________________________________________________________Phone:_________________________________
Organization you are participating with: _________________________________________________________________
Health insurance Co.______________________________________________Policy #: __________________________________
Doctors Name: _____________________________________________________Phone: _______________________________
In case of emergency call: ______________________________________________Phone: _____________________________
YMCA Camp Collins program areas may include, but are not limited to, Challenge Course, Climbing Tower, Aquatics,
Horseback Riding, Sports and Games, Archery, Arts and Crafts, Hiking/Nature activities and evening programs such as Campfires.
Our program areas are designed to meet a wide range of physical abilities and we make reasonable accommodations to serve a
diverse population. Activities may include sitting, walking, running, swimming, wading, jumping, throwing, use of archery
equipment (bows and arrows), riding horses, and contact with craft supplies (paint, glue, dye and potentially hot liquids such as
wax). When utilizing the Challenge Course activities may also include participating in group initiatives on low (2-3 ft. off of the
ground) and high (25-40 ft off the ground) elements, and climbing and traversing on cables, logs and ropes while attached to a
belay (rope) system.
As a participant you are the best judge of your physical abilities and that of your dependent children. There is a
significant element of risk involved in any adventure, sport or activity associated with the outdoors. If you or your dependent
children have a health condition, chronic illness or injury that might be aggravated by doing these activities you should not
participate in these activities without first consulting a physician. Participation in camp activities is voluntary and participants are
able to choose their level of involvement in all activities. In agreeing to participate you assume all liability for any physical injuries
and/or emotional distress suffered by you and/or your dependent children.
RELEASE and WAIVER of LIABILITY and HOLD HARMLESS AGREEMENT
IN CONSIDERATION FOR BEING PERMITTED TO PARTICIPATE IN YMCA CAMP COLLINS PROGRAMMED ACTIVITIES, I AGREE TO THE
FOLLOWING: I hereby accept any and all responsibility for, and assume the risk of any and all injury or damage to my person or
dependent children that might arise directly or indirectly as a result of, and or participation in YMCA Camp Collins program areas
or activities. I hereby expressly release, discharge and hold harmless from any liability, losses, causes of action, expenses and/or
claims for damages whatsoever the YMCA of Columbia-Willamette, the various branches and subdivisions thereof, and all
employees and volunteers in their capacities as representatives of the YMCA, expressly including, but not limited to, the Board
of Directors of the YMCA of Columbia-Willamette, except for injuries caused intentionally or by willful misconduct by such parties.
I certify that I am familiar with the contents of this release, that I have read and understand the same, and that it is my intention
by signing this release that the same be binding not only on me, but my heirs, administrators, executors, successors and assigns.
I understand the risks involved in participation of outdoor recreational activities, and I am fully aware that there may be hazards
and risks unknown to me, and I am physically able to participate in all the program areas listed above. I understand that I am
responsible to pay my own medical and emergency expenses in the event of accident or illness regardless of whether I have
authorized such expense. Furthermore, I am fully aware that the risks, known and unknown, can cause injury, property damage,
illness, mental or emotional trauma, disability or death. This waiver and release will be construed broadly to provide a waiver
and release to the maximum extent permissible under applicable law. Any provisions found to be void or unenforceable shall be
modified or deleted to the minimum extent necessary to make then enforceable, and shall not effect the enforceability of any
other provisions.
I HAVE READ THIS AGREEMENT AND RELEASE, I UNDERSTAND IT, AND I SIGN IT VOLUNTARILY
Signature of Participant: _____________________________________________________Date: _________________________
Signature of Parent/Guardian (if under 18): _____________________________________Date: ________________________
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FRIENDLY REMINDERS
DID YOU………
 COMPLETELY FILL OUT EVERY PAGE (PLEASE!)
 INCLUDE A COPY OF THE INSURANCE CARD, BOTH FRONT & BACK
 HAVE A NOTARY SIGN & SEAL THE NOTARY PAGE
 FOR THE CHILD WITH CANCER, YOUR ONCOLOGIST WILL RECEIVE A MEDICAL FORM TO FILL
OUT. IF A SIBLING IS ATTENDING PLEASE HAVE THE MEDICAL FORM IN SIBLING PACKET FILLED
OUT BY HIS OR HER PHYSICIAN.
 COMPLETE AND INCLUDE THE ELIGIBILITY GUIDELINES (Pg. 4)
 ATTACH A CLOSE UP PICTURE OF YOUR CHILD(REN) or EMAIL A PICTURE TO
[email protected]
 COMPLETE A PICK-UP FORM and a YMCA CAMP COLLINS AGREEMENT TO PARTICIPATE FORM,
FOR BOTH THE CHILDHOOD CANCER SURVIVOR & SIBLING (IF APPLICABLE)
 PACKETS WITH INFORMATION PERTAINING TO THE WEEK OF CAMP WILL BE SENT OUT IN THE
WEEKS PRIOR.
THANK YOU!!!
UNTIL THERE’S A CURE, THERE’S CAMP.
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