Vanderkamp Center
Christian Retreat Center & Summer Camp
337 Martin Road
Cleveland, NY 13042
(315) 675-3651 ¨ (315) 675-8802 (Fax)
Winter Retreat 2014-2015
12/30-1/1
Part 1– Registration
______, ______/___/___ Male/Female
Last Name First Name Date of Birth (circle one)
Mailing Address:______
Street City State Zip
______
Church Name Location Pastor/Adult Leader’s Name
______
Parent or Guardian (Please print) Daytime Telephone Evening Telephone Cell Phone
______
Parent or Guardian (Please print) Daytime Telephone Evening Telephone Cell Phone
Parent/Family email address:______
Part 2 – Payment for Reunion Deadlines
If you have attended in the past, you will notice a price increase this year resulting largely from increased food and energy costs here at Vanderkamp. We are also introducing discounts for families with multiple children in attendance, acquainting new potential kampers with Vanderkamp, and in recognition of the contribution LITs make to our program. If you require kampership assistance, please let us know as we strive to accommodate every child who wishes to attend.
Your total cost for camp is $110 per person for both days. Credit card payments may be made online through PayPal or by cash/check at registration upon arrival. Checks should be payable to Vanderkamp Center. Please contact us prior to the event if you need to make alternative payment arrangements.
Applicable Discounts (Limit one per kamper registration):
□ Sibling discount: $5 off each sibling attending Winter Retreat 2014-2015
Names of attending siblings:______
□ Bring a new friend discount: $5 off returning and new kamper registrations. (Note: “New” kamper must be a youth who did not attend winter retreat 2013-2014, summer kamp 2014 or fall retreat 2014).
Returning kamper name:______
“New” kamper name:______
□ LIT (Leader-in-Training) discount: $5 off registration
Check-in is from 5-6 on the day you arrive and Pickup is at 1 PM on the day you leave. The event starts at 5 PM on Tuesday and goes until 1 PM on Thursday. If you need other arrangements, please let us know!
Vanderkamp Center
Christian Retreat Center & Summer Camp
337 Martin Road
Cleveland, NY 13042
(315) 675-3651 ¨ (315) 675-8802 (Fax)
Winter 2014-2015 Retreat
Emergency Contact Information
Kamper:______Gender:______Birth date:______
(first and last name)
Parent(s)/ Guardian(s):______
(first and last names)
______’s day phone:______’s day phone:______
□ Emergency texts receivable at this/these #’s: ______
□ I/We cannot receive emergency texts.
Evening/home phone: ______OK to leave emergency voicemail □ Yes □No
Emergency Contact during this weekend’s event:
Name:______Relationship to kamper:______
(first and last name)
Day phone:______Evening phone:______
□ This person can receive emergency texts at this number: ______
□ This person cannot receive emergency texts.
The following adults (18 years or older) are authorized to pick- up this kamper, should the above named parent be unable to do so:
Name:______Relationship to kamper:______
Name:______Relationship to kamper:______
Name:______Relationship to kamper:______
Note: A photo ID will be required before the kamper is released into the custody of an adult other than the parent(s) who dropped the kamper off.
Vanderkamp Center
Christian Retreat Center & Summer Camp
337 Martin Road
Cleveland, NY 13042
(315) 675-3651 ¨ (315) 675-8802 (Fax)
Winter 2014-2015 Retreat
Kamper:______Gender:______Birth date:______
(first and last name)
Parent/Guardian Authorization: I have reviewed my kamper’s 2014 summer camp &/or fall retreat health forms and authorizations or submitted currently dated health forms for participation in this event.
□ There have been no changes in my kamper’s health or immunization history including no new allergies, injuries, or other conditions that would limit or otherwise adversely affect my kamper’s ability to participate fully in all programming since these forms were completed.
OR
□ The following changes have occurred in my kamper’s health or immunization history since these forms were completed. Describe in detail—provide additional sheet if necessary:
______
This kamper, ______, has permission to engage in all camp activities except
(first and last name)
as noted here: ______
______
Parent/Guardian (please print):______
(first and last name)
Parent/Guardian Signature:______Date: ______
I understand and agree to abide by any restrictions placed on my participation in camp activities.
Signature of kamper:______Date: ______
Vanderkamp Center
Christian Retreat Center & Summer Camp
337 Martin Road
Cleveland, NY 13042
(315) 675-3651 ¨ (315) 675-8802 (Fax)
Winter 2014-2015 Retreat
Kamper:______Gender:______Birth date:______
(first and last name)
IMPORTANT - This section must be signed for attendance.
I hereby give permission to Vanderkamp and its authorized representatives (i.e., staff or volunteers) to provide, seek and consent to routine health care, administration of prescribed medications, and emergency treatment for my child, as may be needed, including but not limited to: x-rays, routine tests and treatment, or hospitalization. I also give permission toVanderkamp and its authorized representatives to arrange transportation for the camper for said medical treatment or tests. As the child’s parent, I agree to release any medical records necessary for treatment, referral, billing, or insurance purposes.
It is my intention that Vanderkamp and its authorized representatives be treated as acting in loco parentis if my child is a minor. Further it is my intention that authorized representatives of Vanderkamp be treated as “personal representatives” for the purpose of disclosing protected health information pursuant to the privacy regulations promulgated pursuant to the Health Portability and Accountability Act of 1996 (HIPPA). I hereby agree to the disclosure to authorized Vanderkamp representatives of the protected health information of the camper as necessary: (a) to provide relevant information to Vanderkamp related to the child’s ability to participate in camp activities and (b) in the case of minors, to provide relevant information to Vanderkamp to keep me, as the parent, informed of my child’s health status.
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to secure and administer treatment, including hospitalization, for the camper named herein. This form may be photocopied for trips out of camp.
I understand that I will be contacted if my child is exposed to a communicable disease or if medical referral is necessary.
Parent/Guardian (please print):______
(first and last name)
Parent/Guardian Signature:______Date: ______
Vanderkamp Center
Christian Retreat Center & Summer Camp
337 Martin Road
Cleveland, NY 13042
(315) 675-3651 ¨ (315) 675-8802 (Fax)
Winter 2014-2015 Retreat
Releases
Acknowledgment of Risk, Waiver of Liability, and Consent for Treatment:
I acknowledge that there are risks inherent in any children’s program, including but not limited to injury or death arising from: participation in sports activities; waterfront activities, adventure activities, children’s failure to follow instructions of counselors and supervisors; communicable illness; and independent acts of third parties not under the control of counselors and supervisors. I acknowledge that all risks cannot be prevented, and assume those beyond the control of the Vanderkamp staff. Further, I hereby fully and forever waive, release, acquit, hold harmless, and discharge Vanderkamp Center from any and all claims, demands, rights, losses, suits, actions and causes of action, obligations, damages, costs, or expenses of any nature relating to injury of any type suffered during or otherwise arising from any children’s program.
Parent/Guardian Signature: ______Date: ______
I know that I could get hurt doing some activities at Vanderkamp. I know that I am more likely to get hurt if I do not listen to and follow staff instructions or warnings during activities or free time. I will not do anything that I know would hurt me. I will not allow others to do anything that would hurt me. If I am worried about mine or other people’s safety, I will let a counselor, director, or the nurse know right away.
I know I can always say “no” and do not have to participate in any activity that I feel unsafe, even if others choose to participate. Even when staff tell me doing an activity is safe, I know I can always just say “No thank you, I don’t want to do that right now.”
Signature of Kamper:______Date: ______
Audio/Video Release:
I grant permission for audio and video recordings as well as photographs of my child to be used for promotional purposes on behalf of Vanderkamp. Such promotion may include but is not limited to, the web site, Vanderkamp Facebook pages or printed materials like brochures, posters, and flyers. I understand that my child’s name will NOT be used in these promotions.
Parent/Guardian Signature: ______Date: ______
I know I may be in some of the pictures people take while I am at Vanderkamp. It is OK with me if those pictures are shared on Facebook or in brochures where people outside of kamp may see them, like my friends at school. I know these pictures help other people learn about what we do at Vanderkamp and what a great time we have doing it.
Signature of kamper:______Date: ______
Medication Administration OrdersVanderkamp Center ♦ 337 Martin Road ♦ Cleveland, NY 13042
315-675-3651 ♦ / Date of Program:
Please return by:
Kamper’s Name Birth Date
New York State requires written orders for dispensing any medications. This page must be signed by a physician or other licensed medical personnel and by the kamper’s parent/guardian.
STANDING ORDERS FOR OVER-THE-COUNTER MEDICATIONS: The following over-the-counter medications are available at camp. If marked “Yes,” they may be dispensed to the person named above for the indicated conditions, according to label directions. In all cases, generic medications may be used in place of name brands.
YES NO
______Acetaminophen - By mouth for headache, fever, menstrual cramps, or minor pain
______Aloe Vera Gel - Topically for pain related to burns or sunburn
______Bacitracin Antibiotic Ointment - Topically for minor cuts, scrapes, or burns
______Benadryl - By mouth for sneezing, itching, hives, or rash, or swelling due to insect bites or stings
______Cepacol Sore Throat Lozenges - By mouth for minor irritation, pain, sore mouth, or sore throat
______Calamine Lotion - Topical for skin irritation
YES NO
______Hydrocortisone 1% - Topical for skin irritation, itching, or rash
______Ibuprofen - By mouth for headache, fever, menstrual cramps, or minor pain
______Saline Eye Drops - For irritation or redness of the eye
______Sudafed - By mouth for nasal or sinus congestion
______Tums - By mouth for nausea, heartburn, indigestion
ROUTINE MEDICATIONS: The following medications are to be dispensed to the person named above while at camp. List all medications (including both over-the-counter and prescription medications) taken routinely. Bring enough medication to last the entire time at camp. Over-the-counter medications must be delivered to camp in the original packaging. Prescription medications must be delivered to camp in pharmacy packaging that identifies the patient, prescribing physician, the name of the medication, the dosage, the route of administration, and the frequency of administration.
_____ This patient takes NO MEDICATIONS on a routine basis.
_____ This patient takes the following medications on a routine basis:
Medication / Dosage / Route / Schedule / Comments(If more space is needed, please check here ____, and list additional medications on the back.)
Note any medications normally taken during the school year that the camper does not / may not take during the summer:
I authorize the use of the indicated medications in the treatment of this patient.
Signature of health care provider X Date
Printed name License #
I have reviewed this information and agree to its accuracy, and authorize the use of the indicated medications in the care of my child.
Signature of Parent/Guardian X Date
Parent/Guardian Permission - Use of Sunscreen at Vanderkamp
Self Application
I give permission for ______to carry and self apply
(Kamper’s name)
Sunscreen. I understand that the following conditions must be met in order to promote proper and safe use of sunscreen at Vanderkamp:
1) The sunscreen will only be used to prevent overexposure to the sun.
2) Only sunscreen approved by the FDA for over the counter use will be permitted for use by the kamper.
Parent/Guardian Signature: ______Date______
Assisted Application
If ______is unable to apply the sunscreen themselves, I give
(Kamper’s name)
permission for the camp staff to assist in the application of the sunscreen or insect repellent.
Parent/Guardian Signature: ______Date______
Reminder: Sunscreen is considered a drug and shall be checked and logged by Vanderkamp’s health director as such, in accordance with the policies and procedures set forth in their Safety Plan submitted to the Oswego County Health Department.