Camp Cameron Application

Camp Cameron Application

Varennes Heights Baptist Church

411 Visage Drive

Anderson, S.C. 29626

***It would be great if you could include a picture of your child when you return your application so we can place a face with the name.

***You will be contacted by phone when your application has been received and you will send the $25 or $35 application fee at that time to the church office by mail to hold your child’s spot.

Camper’s Name:______Age:______

Date of birth:______Phone number:______

Shirt Size: ______

Address:______Apt#:______

City:______State:______Zip code:______

Does your child have any allergies? If yes, please list:

______

Disability:______

______

Is your child able to communicate verbally or is nonverbal? Does your child use sign language to communicate? If your child uses sign language, please list some signs or include a list of sings that we can use to meet his/her daily needs. ______

______

______

Are there any physical limitations? (Please check the ones that apply): ______Wheelchair

______Walker ______Cane ______Other (For other, please explain):

______

Does your child have problem behaviors?:______If yes, how do you suggest we

Handle the behavior?:(Will an ABA therapist be or personal care assistant be attending?)

______

______

______

Are medications needed during the day?:______If yes, what time of day?:______

How should medications be given (taken orally, feeding tube, crushed, whole, with or without

food)?:______

______

______

List medications that will be given during camp hours:______

______

How does your child use the bathroom? (please check one) _____With assistance

______Independently ______Diaper ______Other(if other, please explain)

______

How does your child do with eating? (please check one) _____With assistance

_____Independently ______Feeding tube ______Cut up in small pieces _____Other (If

other, please explain)______

______

If your child is on a feeding tube, please list step by step, the instructions for how much formula, what the pump should be set on, and how long your child should be on the feedings:

______

______

______

______

______

Please list two contacts that will be available during camp hours if needed:

(1)Emergency contact/relationship:______

(1)Emergency contact phone number:______

(2)Emergency contact/relationship:______

(2) Emergency contact phone number:______

What types of activities does your child enjoy?:______

______

Child’s Favorite songs:______

If your child should have a meltdown, what can we do to transition them?

______

______

______

Is there any additional information that we should know about your child?:______

______

______

______

______

Release Form

I______(Parent/Guardian signature) release Varennes Heights Baptist Church and its volunteers associated with Camp Cameron, of any and all liability during this week of camp.

This includes the following:

•The power to seek appropriate medical treatment or attention on behalf of the child as may be required by the circumstances, including but not limited to, medical doctor and/or hospital visits.

•The power to authorize medical treatment or medical procedures in an emergency situation.

In case of emergency, I understand that every effort will be made to contact parents or guardians of minor campers. However, if parents or guardians cannot be reached, I hereby give Varennes Heights Baptist Church permission to act on my behalf in seeking and administering medical treatment should it be deemed necessary or advisable for the Camper’s health, safety and/or welfare.

Parent’s/Guardian’s Printed Name:______

Parent’s/Guardian’s Signature:______

Date:______

Photographic Release for Minors

Please check one of the boxes below:

______I DO ______I DO NOT

Give Varennes Heights Baptist Church permission to publish in print, electronic, website, or video format the likeness or image of my child.

I release all claims against Varennes Heights Baptist Church with respect to copyright, ownership, and publication, including any claim for compensation related to use of the materials.

Camper’s Name:______

Parent/Guardian Signature:______

General Guidelines:

It is recommended that a release be obtained when photographing or videotaping a minor (under 18). Parent or guardian signatures are required; signatures of minors are not sufficient. When images are published, the Church will take cautionary steps to provide minimum identifying information and will not use a specific street or mailing address, email address, or phone number(s).