CAMPER APPLICATON FORM

CAMP CIVITAN-MICHIGAN

YOUTH AND YOUNG ADULTS WEEKEND

forindividuals with Cognitive ImpairmentAGES 13-50+

CAMP DATES: June 9, 10, 11, 12, 2016

Arrival on Thursday, June 9thbetween 1:30pm-5:00 pm with

Departure on Sunday, June 12th at 11:00 am

Location: CAMPROSENTHAL IN DOWAGIAC, MICHIGAN

$215COST PER CAMPER (DUE WITH APPLICATION)

(Includes 3 nights lodging, 9 meals & a t-shirt)

Make Checks Payable to: MICHIGAN AREA CIVITAN

Application steps:

  1. All applications must come through a local Civitan Club. Local Club should screen camper(s) before you forward.
  1. Non-refundable fee must accompany this application.
  1. Both camper(s) and local Civitan Club will be notified when application and fee have been accepted.
  1. CampDirectors will communicate with camper(s), and their parents/guardians concerning other necessary details.

Send Applications for Camp Civitan-Michigan to:

Cheryl Van Vliet

1576 Walnut Ridge Cr.

Canton, MI 48187

313.460.3194 (cell)

Email:

Application Deadline: April 15, 2016

Keep this 1st Page & Return Pages 2, 3, & 4

Page 1

Sponsoring Civitan Club: ______

Dates: June 9-12, 2016

CAMP CIVITAN-MICHIGAN

CAMPER APPLICATION

(Please type or print clearly.)

Name: ______Nickname:______

Address: ______

Street, City, State & Zip

T-shirt Size: ______

Male ______Female ______Date of Birth: ______

Parent/Guardian: Name and address (if different from camper)

Name: ______

Address: ______

Street, City, State & Zip

Phone: (Home) ______(Cell or Work) ______

Alternate Person to Notify in Case of Emergency:

Name: ______Phone: ______

Health Insurance Co.:______Policy No.:______

MailCampAcceptance Letter to:

Address: ______

Street, City, State & Zip

Camper Personal Skills: Please check any that the camper requires help to perform.

_____ Brushing Teeth_____ Dressing _____Taking Shower_____ Eating

_____ Picking out Clothes _____Tying Shoes_____ Using Toilet

Additional Comments:

______

______

Page 2

Camper Name: ______

Physical Skills: Please check if camper has difficulty with any of these and explain below.

_____ Walking_____ Hearing _____ Speaking_____ Vision

_____ Sleep disturbances_____ Sleep walking_____ Wetting bed or clothing

Additional Comments:

______

______

Does Camper Have Any Dietary Restrictions? List all.

______

______

Has Camper Stayed Overnight Before: ______How Long: ______

Can Camper Sleep in the Top Bunk? ______

Please Explain Any Behavioral or Emotional Difficulties the Camper HAS and HOW the Staff Can Help!!! (We want the camper to have a good experience at Camp so please elaborate.)

______

______

______

List Any Allergies:

______

______

Medications to be Taken at Camp. Meds Must Be Given to the Camp Nurse WHEN the Camper Arrives at Camp. Meds Must Be in Their Prescription Container with Correct Dosage and Times to Be Given.

______

______

______

______

Page 3

RELEASES

TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS COMPLETE AND CORRECT. I HEREBY AUTHORIZE CAMP ROSENTHAL STAFF, CAMP CIVITAN-MICHIGAN, AND THE MICHIGAN AREA OF CIVITAN INTERNATIONAL TO ADMINISTER FIRST AID, MINOR MEDICAL TREATMENT, AND COMMON OVER-THE-COUNTERMEDICATIONS, AND ANY PRESCRIPTION DRUGS I PROVIDE FOR:

______

Camper’s First & Last Name

IN THE EVENT OF ILLNESS OR INJURY, I AUTHORIZE CAMP ROSENTHAL STAFF AND/OR CAMP CIVITAN-MICHIGAN TO PROVIDE OR ARRANGE FOR EMERGENCY CARE OR TREATMENT AND I ASSUME COMPLETE RESPONSIBILITY FOR ANY HOSPITAL, AMBULANCE, OR MEDICAL TEATMENT COST, I UNDERSTAND THAT CAMP CIVITAN-MICHIGAN WILL ATTEMPT TO NOTIFY ME IN SUCH CASES AT:

Phone: ______or ______

I AGREE TO HOLD HARMLESS THE ACTIONS OF THE CAMP ROSENTHAL STAFF, CAMP CIVITAN STAFF AND VOLUNTEERS, CAMP CIVITAN-MICHIGAN, THE MICHIGAN AREA OF CIVITAN INTERNATIONAL AGAINST ANY CLAIMS ARISING FROM BODILY INJURY OR OTHER LOSS DURING THE WEEKEND OF CAMP CIVITAN ATTENDED BY MY OFFSPRING/WARD.

I FURTHER AGREE TO ALLOW PHOTOGRAPHS OR VIDEO TAPING OF CAMPER FOR EDUCATIONAL AND PROMOTIONAL PURPOSES.

I UNDERSTAND THAT I AM RESPONSIBLE TO PROVIDE TRANSPORTATION TO AND FROM THE CAMPAT THE TIMES DESIGNATED ON PAGE 1 OF THIS APPLICATION.

______

SignatureRelationshipDate

If this is their first time at Camp Civitan, please provide a recent photo of camper, if possible.

Page 4