Registration Form

IMPORTANT: ALLINFORMATION IS KEPT CONFIDENTIAL AND USED ONLY FOR EMERGENCY SITUATIONS DURING THE CAMPTERM.

General Information

NameNickname Age___Grade___Birth Date______Sex(circle one) M F

First Last

Address

Street Apt.CityState Zip Code Phone

Are you a returning camper? _____ How many years? _____

Parent/Guardian NameContactPhone

Sponsoring Organization/Church______School attended in 2013______

Check the term you wish to attend: Each camper may only attend ONE Term per summer. Campers must be registered by May 31st to receive the discounted price. A $5.00 fee will be charged for those requesting transportation.

Kids Camp (ages 8-12):Deposit $35 ($40 after May 31st)

NO Term 6 Mini Camp ONLY

____ Term 1 June 23rd- 28th____Term 7 August 11th – 16th

____ Term 2 June 30th- July 5th

____ Term 3 July 7th – 12thMini Camp (ages 6-7): Deposit $15 ($20 after May 31st)

____ Term 4 July 14th – 19th

____ Term 5 July 28th – August 2nd____ Mini Camp I August 4th (5pm) – 6th (7pm)

____ Mini Camp II August 7th (5pm) – 9th (7pm)

A Summer Food form must be correctly completed in order to be eligible to receive a scholarship.

Mail your NONREFUNDABLE deposit and registration form for each camper to:

PVC, 504 Chapel Drive, Ellwood City, PA 16117

HEALTH Information

Family PhysicianPhysician's Phone

Emergency ContactEmergency Contact PhoneRelation to camper

PHYSICAL WELLNESS: Describeany physical illness or mental condition which you are now under treatment:

Is there any condition limiting you from participating in any activity? If yes, please describe.

MEDICATIONS: List any medications you are currently taking; including over-the-counter medications:

ALLERGIES: Listanymedications (penicillin, sulfa, tetanus, antitoxin,etc.), bites/stings or foods to which you are allergic. What is the reaction?:

CHECK “Yes” or “No” if you now have or have had any of the following:

Symptoms/Conditions / Yes / No / Symptoms/Conditions / Yes / No
Dizziness, loss of consciousness, or recent headaches / Asthma
Eye, ear, nose, throat or sinus symptoms / Symptoms, related to the gastrointestinal tract, recurring abdominal pain, etc…
Impaired of sight, hearing, or speech / Albumin, sugar or blood in urine; kidney stone or other urinary difficulties
Chronic cough or coughing up of blood / Muscle, joint or back pain, bursitis
Chest Pain, palpitation, heart murmur, high blood pressure, heart condition / Any condition limiting you from participation in any activity
Leg cramps, varicose veins, or varicose ulcer

If you checked “Yes” above, please describe:

Date of Last Physical Exam: ______Are your immunizations current? _____ Date of last Tetanus ____-_____-_____

History of Childs medical treatment (i.e., surgeries)

Insurance Company and Group Number:

***PLEASE FILL OUT BOTH SIDES OF THIS FORM, theMission Vision Form and Summer Food Form****

HEALTH PERMISSIONS: CHECK “Yes” or “No”

I give my permission for the administration of currently prescribed drugs prescribed by your physician. Please make sure your medications are in their original container. /  Yes  No
I give my permission to treat minor complaints following the camp policy and procedure listed below; and when needed, the use of over the counter medication under the supervision of the camp nurse. /  Yes  No

I give my permission for the administration of the following medication(s), or generic equivalents, to be determined by the camp nurse. PLEASE CHECK all medication(s) that may be administered to the camper/staff. Appropriate dosages are based on manufacturer’s guidelines and child’s weight.

Advil (Ibuprofen) / Chloraseptic (Spray/Lozenges/Cough Syrup) / Maalox / Tylenol
Benadryl / Imodium AD / Decongestant / Topical ointments/creams

Signature of Parent/Guardian:Date signed:

Parent(s) or legal guardian(s) of a camper or staff will be notified by the Executive Director, camp nurse, or designate, in the event of an illness or injury requiring treatment at the Ellwood City Hospital.

  • If the illness or injury requires the camper/staff to be seen by medical personnel other than the camp nurse, you will be notified to determine if you want your child to be seen at the EllwoodCityHospital or your own private physician.
  • In an emergency illness or injury requiring immediate treatment by EllwoodCityHospital, you will be notified by the Executive Director or his designate as soon as possible.
  • If you want to be notified other than in these situations, please inform the camp nurse in writing at registration.

angel tree scholarship information

Does the child have a parent that is currently incarcerated? □Yes - mother or father? (Circle which one)

This information would enable us to apply for scholarship money from Angel Tree.

Children of an incarcerated parent will receive a $10 Camp Store credit.

 CHECK if enrolled with CYF of Allegheny County: Case workers Name ______Case #______

PART 1:CHILD’S NAME:

PART 2:SIGNATURE—THIS SECTION MUST BE COMPLETED AND SIGNED BY AN ADULT FOR ALL CAMPERS

PARENT OR GUARDIAN DISCLOSURE AND INDEMNIFICATION (Must be completed for participants under the age of 18)

This is in consideration of the above-named camper being permitted by PVC to participate in its activities and to use its equipment and facilities. I agree to indemnify and hold harmless PVC from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such use or participation by Minor regarding:

  • In the event of an emergency, I hereby give my permission to the instructor to hospitalize, secure proper treatment, and to order injections, anesthesia, or surgery.
  • I give my permission for any pictures and personal quotes to be used for promoting the camp program at PVBC.
  • I understand there is transportation of campers for off-site trip days and possibly to & from their neighborhoods to camp. Campers may be bused to a local state park and if camper is old enough will be taken on the river trip which is also off-site.
  • I understand that there are no private changing rooms offered in the cabins.

Signature of Parent/Guardian: Social Security #______-____-______

Printed name of Parent/Guardian: Date signed

Street: Apt. City State Zip Code

Home Phone Work Phone Cell Phone

PART 3:Racial/Ethnic Identity—CHECKall that apply.(Information is not required, but if provided, aides in scholarship awards.)

[ ] White / [ ] African American / [ ] Hispanic or Latino / [ ] Asian / [ ] Native Hawaiian/Other Pacific Islander / [ ] Am. Indian/Alaskan Native

Income guidelines for Summer Food Service Program – Effective July 1st, 2012 to June 30, 2013

Household sizeAnnual EarningsMonthly EarningsWeekly Earnings

1 $0-20,665 $0-1,723 $0-398

2 $0-27,991 $0-2,333 $0-539

3 $0-35,317 $0-2,944 $0-680

4 $0-42,348 $0-3,554 $0-821

5 $0-49,969 $0-4,165 $0-961

6 $0-57,295 $0-4,775 $0-1,102

7 $0-64,621 $0-5,386 $0-1,243

8 $0-71,947 $0-5,996 $0-1,384

For each additional +$7,326 +$611 +$141

Household memberYou must fill correctly complete a summer food form to apply for income eligibility.