1.) You and Your Child Must Complete the Entire Application

September 2017

Dear Parent(s):

We are now approaching our 2017 Camp SuperStars Sibling Retreat, which will take place on Saturday, October 28, through Sunday, October 29, 2017! This is a wonderful opportunity for your child to meet other siblings, to have fun and to process the many feelings and emotions that occur from the impact of childhood cancer in the family. Our goal is to assist you in emphasizing your child’s unique role to their family and to remind them of how much they are valued and loved.

We will be conducting our Sibling Retreat at a different facility this year. We will be doing an overnight at the Explora Children’s Museum! The address is: 1701 Mountain Rd NW, Albuquerque, NM 87104. Drop-off will be at the Albuquerque Botanic Garden at 9:00am on Saturday, October 28. The address is 2601 Central Ave. NW, 87104.

This application includes the Camp SuperStar Sibling Retreat 2017 registration materials. You and your child(ren) need to complete the general information and consent forms. If you have more than one child attending please print copies of the packet and fill out a separate application for each child.

In order to attend:

1.)  You and your child must complete the entire application.

2.)  Any child attending the retreat MUST see a doctor and receive a doctor’s approval to attend.

3.)  Please make note of the dates and times!

Each year we request that you (parent or guardian) write a special letter called a Palanka letter – to your child expressing your thoughts, feelings and special hopes for them. We like to use this opportunity for your child to hear from your heart how much they truly mean to you. This letter is given to your child during the closing ceremony; where they are given special time to reflect on your special message. For new campers, we are asking that you keep this letter a surprise for the children.

In order to do so, please do one of the following:

ü  Mail the letters to “Camp Enchantment” at 12231 Academy Rd. NE #301-310 Albuquerque, NM 87111 no later than October 15, 2017.

ü  On Saturday, October 28th, bring them with you and discretely give them to a staff member

If you have any questions about this letter, please contact Raquel Luchini @ 505-944-6329 or

Thank you for your participation.

Sincerely Your Camp Super Stars Staff

PLEASE PRINT

Birth Date______Gender______Age______Vegetarian: Circle one Yes No

Camper:______

Last Name First Name

Sibling Camper Name: ______

Last Name First Name Nickname

Mother/Guardian 1: ______

Last Name First Name

______

Home Address City/State Zip

Home Phone(_____)______Cell/Alt Phone(_____)______

Work Phone (_____)______Email address:______@______

Father/Guardian 2: ______

Last Name First Name

______

Home Address City/State Zip

Home Phone(_____)______Cell/Alt Phone(_____)______

Work Phone (_____)______Email address:______@______

Emergency Contact: ______Relationship to Camper______

If we are unable to reach you

Home Phone Cell/Alt Phone Work Phone______

Ethnicity: (We use this information to determine the diversity of our campers.)

___ Caucasian ___ Black ___ Hispanic ___ Asian ___ American Indian ___ Other (please specify)

HEALTH HISTORY

Condition When Condition When Diseases When

Ear Infection ______Ostomy ______Chicken Pox ______

Heart Disease ______Bedwetting ______Measles ______

Convulsions ______Sleepwalking ______German measles ______

Diabetes ______Prosthesis ______Mumps ______

Bleeding Disorder ______Asthma ______

MENTAL HEALTH HISTORY

Does your child have any of the following mental health condition?

ADD ______ADHD ______BIPOLAR ______ANXIETYY ______

DEPRESSION ______LOSS AND GRIEF ______OCD (Obsessive Compulsive Disorder) _____

ODD (Opposition Defiant Disorder) ______

Other: Please explain fully ______

Are they being treated by a counselor or doctor for their mental health concern? Yes ____ No _____

EXPOSURE

***Important: Please notify the medical staff if camper is exposed to chicken pox, lice or any infectious disease within three weeks prior to camp attendance.

ALLERGIES

Hay Fever ______Plants (type):______

Insect Stings (type) ______

Medication(s) camper is allergic to: ______

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 Peers Level: ______

SPECIAL ACTIVITIES-OF-DAILY-LIVING NEEDS

Outline any assistance needed by your son/daughter:

Dressing: ______Eating: ______

Toileting: ______

Walking from place to place: ______

(i.e. needs a wheelchair, physical assistance, etc.)

OTHER ACTIVITIES

Any specific activities to be encouraged? ______

Any specific activities to be discouraged? ______

Can your child swim 25 feet without assistance? (With supervision) Yes ______No ______

Dietary modifications? ______

Does your child have any special psychological needs? If so, what? ______

______

______

GENERAL QUESTIONS (Explain "yes" answers below)

Has/does the participant: Yes No Yes No

1. Had any recent injury, illness, 15. Had back problems?

or any infectious disease? 16. Had problems with joints?

2. Has a chronic or recurring 17. Have an orthodontic appliance

illness/condition? being brought to camp?

3. Been hospitalized? 18. Have any skin problems

4. Had surgery? (e.g. itching, rash, acne)?

5. Has frequent headaches? 19. Had mononucleosis in the past

6. Ever had a head injury? 12 months?

7. Been knocked unconscious? 20. Had problems with diarrhea/

8. Wear glasses, contacts, or constipation?

protective eye wear? 21. If female, have an abnormal

9. Passed out during or after menstrual history? exercise? 22. Had an eating disorder?

10. Been dizzy during or 23. Had emotional difficulties

after exercise? for which professional help

11. Had seizures? was sought?

12. Had chest pain during or

after exercise?

13. Had high blood pressure?

14. Been diagnosed with a

heart murmur?

Please explain any "yes" answers, noting the number of the question.

______

IMMUNIZATION Please give all dates of immunizations or attach a clean copy of immunization records.

Vaccine Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr

DTP ______

TD (tetanus/diphtheria) ______

Tetanus ______

Polio ______

MMR ______

or Measles ______

or Mumps ______TB Mantou

or Rubella ______Date of last test ______

Heamophilus influenza B ______Result: Positive Negative

Hepatitis B ______

Varicella (chicken pox) ______

BCG _____

DENTIST

Name of Dentist/Orthodontist______Phone (______)______

To be completed by parent or guardian

CONSENT FORM

Authorization for Treatment

In consideration of this camping opportunity, applicant does thereby agree to indemnify and hold Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat harmless from any claims for accident or injury sustained by the camper named in this form while attending or participating in any Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat program on or off the camp premises.

I further consent to any routine or non-surgical medical care that my child/ward may be required to have either due to circumstances previous to or during the camp sessions.

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/ward as named below.

Your signature is required below or we will not be able to accept your child at camp.

Medical Emergency Authorization

As the parent/legal guardian of ______ (please print name of Camp Participant),

I give full authorization to Camp Enchantment New Mexico and Camp SuperStar their employees, agents, volunteers, or designated chaperones to secure medical care or treatment for said youth. This treatment may include assistance from the nearest physician, medical clinic, hospital, trained nurse or EMT in the event of illness or injury that requires immediate attention, as determined by the event staff. In the event that I cannot be contacted, and an emergency has occurred, I give permission to the treating medical institution and/or medical providers to hospitalize and administer the appropriate treatment deemed medically necessary for my child/ward.

Print Camper’s Name

Print Parent / Guardian name

Signature of Parent or Legal Guardian Date

In case of emergency, we will make every effort to contact parent/legal guardian, and/or your designee.

PHYSICIAN to complete pages 7-8

PHYSICIAN INFORMATION & MEDICAL EXAMINATION

MEDICAL INFORMATION

Please fill in the following: S=Satisfactory, N=Not Satisfactory (explain) and O= Not examined

Height ______Weight ______Blood Pressure ______Urinalysis ______

Eyes_____ Lungs_____ Allergy (specify) ______

Glasses_____ Abdomen_____ Ears_____ Hernia______

Nose _____ Extremities _____ General Appraisal: ______

Throat _____ Posture (spine)_____ Heart_____Skin______

MEDICATIONS BEING TAKEN

Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Campers should bring enough medications to last the entire time at camp. Keep medication in the original packing/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage and the frequency of administration.

Indicate with an (X)

____ This person takes NO medications on a routine basis.

____ This person takes medications as follows:

Med. #1 ______Dosage ______Specific times taken each day______

Reason for taking ______

Med. #2 ______Dosage ______Specific times taken each day______

Reason for taking ______

Med. #3 ______Dosage ______Specific times taken each day ______

Reason for taking ______

* * Attach additional pages to list more medications.

Does this child have any of the following mental health condition?

ADD ______ADHD ______BIPOLAR ______ANXIETYY ______DEPRESSION ______

LOSS AND GRIEF ______OCD (Obsessive Compulsive Disorder) _____

ODD (Opposition Defiant Disorder) ______

Other: Please explain fully ______

Identify any medications taken during the school year that participant does not take during the summer.______

Special Instructions: ______

General recommendations and restrictions while at Camp:

Activity restrictions: ______

______

Special dietary needs, restrictions: ______

______

Other special needs, restrictions: ______

______

Additional health information/comments/needs/concerns? ______

______

______

PHYSICIAN INFORMATION

I have examined (child first/last name) ______

In my opinion, the above child's treatment/diagnosis does ___ does not ___ prevent participation in the active camp program.

Licensed Physician's Signature ______

Print Physician's Name ______Date______

Office Address ______

Office Phone (______) ______

Consent to participate / permission form / transportation

I hereby request and consent that my child or ward, ______be permitted to travel to and from several locations and participate in the Camp Enchantment New Mexico Sibling Retreat.

I agree to and understand the following:

My child or ward may be accompanied and transported by Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat officials sponsoring SuperStar Sibling Retreat; however, neither Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat, nor its employees, agents, or volunteers assume any liability whatsoever by such accompaniment or transportation.

I agree that neither Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat, nor its employees, agents, or volunteers associated with the Camp SuperStar Sibling Retreat shall be held responsible for any injuries or damages that occur while my child or ward is traveling to or from such Camp SuperStar Sibling Retreat or during the time my child or ward is in attendance at or is participating in the Camp SuperStar Sibling Retreat.

I do hereby hold harmless Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat and, its employees, agents, and volunteers, against any and all liability, damage, loss, claims or demands which arise out of or are in any way connected with my child/ward’s travel to and from, attendance at, or participation in, the Camp SuperStar Sibling Retreat.

I hereby authorize any Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat and employee, agent, volunteer, or designated chaperone to consent to emergency medical treatment as necessary for the health and safety of my child/ward. I further agree that no Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat and employee, agent, volunteer, or designated chaperone shall be held responsible for injuries or damages arising from the provision of any such emergency medical treatment. I also authorize the medical institution and/or medical providers to hospitalize and administer the appropriate treatment deemed medically necessary for my child or ward.

I do hereby agree to indemnify to hold harmless Camp Enchantment New Mexico and Camp SuperStar Sibling Retreat and any employee, agent, volunteer, or designated chaperone 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 understand that Camp SuperStar Sibling Retreat staff will, when the health, well-being or safety of campers is at risk, use their discretion to search camper belongings. Any items deemed illegal or unsafe will be seized and appropriate action will be taken.

I further understand that if my child/ward has any body piercing, they participate in all camp activities at their own risk. Any piercing below the neck will be covered at all times. If medical personnel deem a piercing unsafe, the camper may be required to remove it.

Continued: Participation, Transportation, -

I ______give my consent for my child/ward to participate in such possible activities as: hiking, swimming, mini-golf, dancing, running, playing, and other activities.

I understand that this is an innovative clinical program using a variety of outdoor settings and activities that have some inherent physical risks. Every possible safety measure has been designed into the program (highly trained staff, state-of-the-field equipment, and strict safety standards) to safeguard all participants against possible injuries. I understand that if I have any questions about the activities, I can make an appointment to discuss it with a staff person from the program.

I understand that during such activities as: hiking, swimming, mini-golf, dancing, running and playing, and other activities, there are risks of injuries, falling, equipment failure or being hit by falling objects dislodged by others or by the force of nature, and that by electing to participate in such activities, my child/ward shall be deemed to have assumed the risk of accident or injury.

I also understand that not all campers will participate in all of the above activities. Age and physical abilities and activity availability will determine appropriate activities.

Parent/Guardian Signature ______