2011 Camper Application
Camp Amazing Grace is a program of the Prison Ministry Task Force of the Episcopal Diocese of Maryland. In 2011, we plan to accept 18-27 campers aged 8-11. Camp Amazing Graceis an oasis of carefor Maryland children whose parents are incarcerated. Our goal is to ensure these children are:
¶ loved and accepted;
¶ given the gift of a week away from the routines of everyday life;
¶ invited to spend restorative timeenjoying the beauty of God's creation;
¶ encouraged to embrace their own creativity;
¶ offered new supportive friendships;
¶ given the opportunity to develop life skills; and
¶ provided the experience of sharing the love of God for all people in community.
Providing the requested information in this camper application is a requirement for all campers that wish to participate in camp week, August 14-19, 2011. Deadline to submit application is May 30, 2011.
Camper’s name:______Gender: ___ Birth date: ______
Parent or Guardian’s name:______Gender: ____
Home address: ______
Street city state zip
Home Phone: ______Cell Phone: ______E-Mail Address: ______
Camper’s T-shirt size – Child’s Small_____ Medium_____ Large_____ Adult (S-M-L)______
If you have a parent in the prison system, please provide their name:
Location:
Facility name city state
How did you hear about Camp Amazing Grace? ______
Grades (2010-2011 school year): School:
name city
Is applicant eligible for school breakfast/lunch program?
Camper’s signature______Date: ______
I certify that answers given here are correct to the best of my knowledge. I authorize investigation into any information contained in this application. You have my permission to talk with the applicant’s school social worker, psychologist and/or teacher(s) for academic and behavioral background information. I agree to hold harmless the Diocese of Maryland and the Bishop Claggett Center, its officers, employees, and volunteers from any liability relating to any investigation they undertake in good faith regarding the information in this application, or any action taken a result of that investigation. I also understand that signing this application gives permission to use photographs of camp-related events for publicity and fund-raising.
Parent or Guardian’s signature: Date______
Please mail your signed application to: For information, call Maria-Robinson Conaway,
Camp Amazing Grace Executive Director, 410-523-0191
Att.: Kathrine Ebert
Diocesan Center
4 E University Parkway
Baltimore MD 21218-2437
Bishop Claggett Center
Health Information Form
Parent or guardian must complete this form and submit it with the camp application. No camper will be permitted to stay at Claggett without the advance receipt of the completed and signed form. Please print clearly in ink.
Camper’s Full Name: ______
Date of Birth: ______Age: ______Gender: ______
Name of Parent or Guardian: ______Home Phone: ______
Work Phone: ______Cell Phone: ______
Home Address: ______City: ______State: ___ Zip: ______
If the person above is not available in the event of an emergency, notify:
Name: ______Relationship: ______Phone: ______
Name: ______Relationship: ______Phone: ______
Name of Personal Physician: ______Phone: ______
Insurance Information: Carrier: ______Plan #: ______
Primary Insured: ______Policy #: ______
Allergies - check here if none [ ] List What happens when exposed? (ex: rash, swelling) Medications: ______
Foods ______
Insects/bee stings ______
Plants/animals ______
Other ______
General Health Information: Check all items that apply to your health history, past or present. Explain any yes answers.
YES NO YES NO YES NO
Asthma [ ] [ ] Diabetes [ ] [ ] High Blood Pressure [ ] [ ]
ADD/ADHD [ ] [ ] Digestion [ ] [ ] Kidney Disease [ ] [ ]
Cancer/Leukemia [ ] [ ] Heart Trouble [ ] [ ] Lungs [ ] [ ]
Convulsions/Seizures [ ] [ ] Hemophilia [ ] [ ] Mental Illness [ ] [ ]
Eyes, Ears, Nose, Throat [ ] [ ] Takes Prescriptions Daily [ ] [ ]
Explain: ______
Check any your child prone to: headaches [ ], Sore Throats [ ], Bed wetting [ ], Sunburn [ ], Poison Ivy [ ], Colds/Fever [ ], Stomach Aches [ ], Sprains [ ], Nightmares [ ], Swimmer’s Ear [ ], Menstrual Cramps [ ]
List any medications to be taken at camp. ______
List any physical, emotional, or behavioral conditions that may affect or limit full participation in any camp activity: ______
______
List any special medical equipment needed such as braces, glasses, etc. ______
How would you like us to handle homesickness? ______
Non-Prescription Medication
Please check any medication that the health care provider may give the camper:
Tylenol [ ] Motrin/Advil [ ] Benadryl [ ] Sudafed [ ] Pepto-Bismol [ ]
Milk of Magnesia [ ] Tums/ Maalox [ ] throat lozenges/spray [ ]
Other: ______
Health Information Form, continued Camper’s Full Name:
The following lotions/ointments may be administered by the nurse:
antibiotic ointment Benadryl cream Hydrocortisone cream
antifungal cream first aid cream anti-itch cream antiseptic wash
Caladryl lotion ear drops (swimmer’s ear) eye wash (for foreign body)
List any the camper should not have: ______
Important! Immunization Record Required
According to state regulations, each camper must submit a copy of their immunization (shots) record. If you do not have a copy, sign and send with the camper the letter on page 7 to their school, clinic or doctor to request a copy of those records. The signed copy must be submitted along with this application.
In case of emergency, I understand every effort will be made to contact me. In the event I can not be reached, I hereby give my permission for Bishop Claggett Center, the Center’s designee, or the Episcopal Diocese of Maryland to secure proper treatment for the person named on this form, including hospitalization, surgery, anesthesia, or the administration of any medication oral or injected.
I agree to be responsible for all costs associated with such treatment.
Date: ______Signature of Parent or Guardian: ______
Print Full Name of camper: ______
All medications must be checked in with the health care provider at registration.
All medications must be in their ORIGINAL containers with the camper’s name and the dosage clearly visible. Medications must be given as per the directions on the prescription container.
Medication Chart
Dosage and Time to Be Given
Medication
/ Pre-Breakfast / Breakfast / Lunch / Dinner / Night / Other / As Needed1.
2.
3.
4.
5.
6.
Other Instructions:
Bishop Claggett Center
Community Living Covenant
Claggett youth programs are a place where participants and staff can live out their faith in ways that are fun and exciting. The formation of an intentional Christian community gives the participants an opportunity to come part from the world and to experience God’s love in a more intense way. Participation in this type of community is a privilege, and requires some sacrifice as we strive to have our actions reflect the model set forth by Jesus.
Bishop Claggett Center camps and youth activities are subject to the Code of Maryland Regulations governing youth camps. As we work with the State on compliance, more written policies will be developed and enforced. As we work to build community and comply with new policies and procedures, each participant is asked to pledge his or her commitment to live by certain community standards.
Cooperation and respect are the starting points for behavior that builds community.
I will demonstrate respect for myself by:
¨ *Refraining from the use of drugs, alcohol, and tobacco.
¨ Abiding by all safety procedures.
¨ Having a willing attitude toward participating in camp activities.
I will demonstrate respect for others by:
¨ Building others up with positive comments and encouragement.
¨ Focusing on people rather than things. I therefore agree to leave items such as electronic games, CD players, boom boxes, and cell phones at home.
¨ *Leaving weapons at home (including pocket knives, pen knives, and hunting knives).
¨ Abstaining from sexual contact with others.
¨ Working to ensure the safety and health of others.
¨ By abiding by the rules and times set for lights out and quiet times.
I demonstrate respect for authority and Claggett property by:
¨ Cooperating with the staff.
¨ Agreeing that the Camp Amazing Grace Camp Directors, the Executive Director of Claggett, or their designee may search my belongings at any time.
¨ Abiding by the rules for use of buildings and equipment.
I understand that the Camp Amazing Grace Camp Directors have the right to send me home at the expense of my parent or guardian if my conduct is disruptive and harmful to the community. Violation of any item marked with an asterisk will mean immediate dismissal from camp.
Please write what excites you about coming to camp? ______
______
______
This covenant must be signed by the participant and parent or guardian. Parent or guardian, please be certain that you have reviewed the agreement with your youth. It will also be reviewed at registration and an additional signature will be required. Your signature indicates a willingness to abide by the standards listed in this pledge and in the general policies.
Print camper’s nameCamper’s signature / Date:
Print parent/guardian’s name
Parent/guardian’s signature / Date:
BISHOP CLAGGETT CENTER
P.O. BOX 40
BUCKEYSTOWN, MD 21717
301-874-5147
ACTIVITY RELEASE FORM
MUST BE COMPLETED TO PARTICIPATE IN CLAGGETT PROGRAMS
1. During the course of our programs, campers and staff will have the opportunity to participate in various activities that involve unusual risks. For example; campers and staff may participate in a high and/or low ropes course activity with potential for slips and falls which could result in scratches, bruises, sprains, lacerations, fractures, concussions, or even more life threatening injuries. Campers and staff may also participate in canoe trips, hikes, bike trips, outdoor games, and various other physical activities that present an unusually high risk for injury.
2. I acknowledge that my/my child’s participation in activities while at camp entails known and unanticipated risks, which could result in physical or emotional injury. While particular rules, equipment, and personal discipline may reduce the risk, the possibility of serious injury does exist. I understand that such risks cannot be eliminated without jeopardizing the essential qualities of the activities.
3. On behalf of myself/my minor child, I expressly agree and promise to accept and assume all of the risks existing in these activities. I recognize that my/my child’s participation in these activities is purely voluntary and I authorize his or her participation in spite of the risks.
4. I certify that I have adequate insurance to cover treatment of any injury suffered by me/my minor child while participating in adventure activities or else I agree to bear the costs of such injury myself.
By signing below, I hereby voluntarily release the Bishop Claggett Center, it’s agents, lessees, owners, officer, volunteers, participants, employees and other persons or entities acting in any capacity on it’s behalf from any and all claims, demands, or causes of action that are in any way connected with my/my minor child’s ______(print minor child’s name) participation in adventure activities.
Print Camper nameCamper’s signature / Date:
Print Parent/Guardian name
Parent/Guardian Signature / Date:
Upward Enterprises, Inc.
Must be completed to participate in Ropes Challenge Course
In consideration of being allowed to participate in any way in the Upward Enterprises, Inc. Program, its related events and activities I acknowledge, appreciate and agree that:
1. The risk of injury from the activities involved in this program such as Ropes Challenge Course and portable games and activities is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce risk, the risk of serious injury does exist and,
2. I knowingly and freely assume all such risks, both known and unknown, and assume full responsibility for my participation and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives, and next of kin, hereby release, indemnify, and hold blameless Upward Enterprises Inc., the officers, officials, agents, and employees, other participants, sponsoring agencies, advertisers, and, the owners and leasers of the premises used to conduct the event, with respect to any and all injury, disability, death, or loss or damage to person or property, to the fullest extent permitted by law.
5. Upward Enterprises, Inc. reserves the right to use any and all photos and videos for marketing promotional purposes.
6. The Venue of any dispute that may arise out of this agreement, or otherwise, between the parties to which Upward Enterprises, Inc. or its agents is a party, shall be either the U.S. District Court of Frederick County, Maryland, or the State Supreme Court of Maryland.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
X______Age: ______Date ______
Participants Signature
FOR PARENTS/GUARDIANS OF PARTICIPANTS UNDER AGE 18
This is to certify that I, as parent/ guardian with legal responsibility for this participant, do consent and agree to his/ her release as provided above of all Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, to the fullest extent permitted by law.
______Date______
PARENT/ GUARDIAN SIGNATURE EMERGENCY PHONE NUMBERS
Medical Registration Form
Prior conditioning is strongly recommended. On all of our outings, clients are expected to take personal responsibility for their own safety. Please consider the statements below carefully as you complete this Medical Registration Form. Name______E-mail______
Address______City______State______Zip______
Home Phone______Work Phone______
Who to Contact in Case of Emergency: Name______Phone______