2015 Camp UKANDU â SIBLING Registration Packet
Camp UKANDU SIBLING 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 registration form(s). There are separate packets for the “survivor” and for the “sibling”. The Sibling application includes detailed medical information, and requires a medical examination (or school sports physical) 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’s Camp Collins, in Gresham, OR. For more information on YMCA’s 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 - Sibling 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: Brothers and sisters of a child with diagnosis of cancer or child having BMT/ SCT. Each family can have a sibling at camp for two years. Brothers and sisters who have lost a sibling due to cancer, BMT/SCT within two years may attend camp for one year. 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, Suite 2300 Portland, OR 97204 4 2015 Camp UKANDU Registration Packet Information Sibling 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 Sibling 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 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 #) What is the name of the brother or sister that has cancer?: ________________________________ What type of cancer does he/she have?: _______________________________________________ Date of cancer diagnosis:___________________________________________________________ Month & Year Is he/she still on therapy? (Chemotherapy, Radiation, Bone Marrow Transplant, Stem Cell Transplant): Yes _____ No______ If no, when was the therapy discontinued?: ____________________________________________ Month & Year Have you attended Camp UKANDU before? Yes _____ No ____ If yes, what year(s)?: ____________ Have any other siblings attended Camp UKANDU? Yes_______________ No__________________ If yes, what are their names and what year(s) did they attend?_____________________________ _______________________________________________________________________________ 6 2015 Camp UKANDU Medical Form Sibling 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: ___________________________________ IMMUNIZATION Please give all dates of immunizations Vaccine Dates: Mo/Yr Tetanus (most recent) __________ 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? ________________________________________ 7 2015 Camp UKANDU Medical Form Sibling Registration Packet HEALTH HISTORY – Pg. 2 Camper’s Name: ___________________________________ 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?_______________________________________ _______________________________________________________________________________ SECONDARY MEDICAL CONDITIONS Indicate with an (X) any of the following conditions exhibited by your child; please provide detailed information about his/her limitations. Do not hesitate to use an additional sheet in providing information which would help us better understand your child. _______ Visual Impairments:__________________________________________________________ _______ Hearing Impairments:________________________________________________________ _______ Learning Disabilities:_________________________________________________________ _______ Cognitively (Academically) Functions Below Peer Level:_____________________________ OTHER ACTIVITIES Any restrictions on activity level? Yes____ No____ If “YES”, please explain _____________________ _________________________________________________________________________________ Have any dietary modifications? Yes____ No____ If “YES”, please explain______________________ _________________________________________________________________________________ Can your child swim without assistance? (Not without supervision) Yes ______ No ______ 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 ________________________________________________ _________________________________________________________________________________ 8 2015 Camp UKANDU Medical Form Sibling Registration Packet HEALTH HISTORY – Pg. 3 Camper’s Name: ___________________________________ EXPOSURE *Important: Please notify us if your 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 arrivals. Should your child be found to have lice, they will not be allowed to attend camp until they have been treated at home and checked by medical staff at camp. If you have questions regarding this policy please contact the camp office. Camper First Name:___________________ Last Name:__________________________ 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!! 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 9 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 10 Camper’s Name: _____________________________ 2015 Camp UKANDU Medication Schedule Form Sibling 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 Time Sun Mon Tue Wed Thur Fri Sat 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 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: ______________________________________________________________________ 11 2015 Camp UKANDU Physician Information & Medical Exam Sibling Registration Packet Camper’s Name: ___________________________________ PHYSICIAN INFORMATION & MEDICAL EXAMINATION for SIBLING – A copy of a school physical is an acceptable substitute. MEDICAL INFORMATION – NEEDS TO BE FILLED OUT BY A DOCTOR EVEN IF THEY ARE NOT THE CANCER PATIENT Please fill in using: Height Eyes S = Satisfactory _____ _____ N = Not Satisfactory (explain) Weight _________ Lungs Abdomen _____ _____ O = Not examined Blood Pressure _________ Allergy (specify) ______________________ ______________________________________ Ears _____ Hernia _____ Nose _____ Extremities _____ General Appraisal: _______________________ Throat _____ Posture(spine)____ ______________________________________ Heart _____ Skin _____ Reccomendations and restrictions while at camp: _____________________________________ ______________________________________________________________________________ Activity: _______________________________________________________________________ Additional health information/comments/needs?______________________________________ ______________________________________________________________________________ PHYSICIAN INFORMATION I have examined ___________________________________________________________________. In my opinion, The child is clear to participate at Camp UKANDU _____ The child is NOT clear to participate at Camp UKANDU ______ Licensed Physician's Signature ___________________________________________________ Print Physician's Name _________________________________________Date_____________ Address _________________________________________________Phone ________________ 12 2015 Camp UKANDU Parent/Guardian Letter Sibling 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: 13 2015 Camp UKANDU Parent/Guardian Letter Sibling 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: 14 2015 Camp UKANDU Camper Letter Sibling 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: 15 2015 Camp UKANDU Health Insurance Information Form Sibling 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 16 2015 Camp UKANDU Authorization For Treatment Sibling 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: _____________________________________________________ 17 2015 Camp UKANDU Camper Participation Consent Form Sibling 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 18 2015 Camp UKANDU Camper Behavior Expectations Sibling 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 19 2015 Camp UKANDU Adult Authorization for Pick-up Sibling 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:______________________________________________________________ 20 2015 Camp UKANDU Adult Authorization for Pick-up Sibling 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! 21 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: _________________________ 22 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 SIBLING ATTENDING PLEASE HAVE THE MEDICAL FORM IN THIS PACKET FILLED OUT BY HIS OR HER PHYSICIAN. COMPLETE AND INCLUDE THE ELIGIBILITY GUIDELINES (Pg. 4) ATTACH A CLOSE UP PICTURE OF YOUR CHILD or email a picture to [email protected] COMPLETE THE PICK-UP FORM and a YMCA CAMP COLLINS AGREEMENT TO PARTICIPATE FORM 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. 23
© Copyright 2024