2016 Indiana State Police Camp

Application

- 800-671-9851 –

Career CampsOptimist/ Lions Law Camp

(Grades 9-12) Registration Fee: $250.00(Grades 6-8) Registration Fee $150.00

Trine University, Angola………………… July 10-15 Anderson University, Anderson…………… July 6-9

Vincennes University, Vincennes….. July10-15 Vincennes University, Vincennes………June15-18

Camper Information
Last Name
/ First Name
/ MI
/ Date of Birth / Age
/ Gender

Address
/ State
/ Zip
/ County

Parent/ Guardian Primary Phone # -- Name

Parent/ Guardian Email
/ 2n Parent/ Guardian Primary Phone # –Name

2nd Parent/ Guardian Email

Emergency Contact (Additional—Not listed above)
Name: Phone #

Relationship to Camper: / Camper Primary Phone Number (If Applicable)

Camper Email (If Applicable)

Campers my request one (1) Roommate:
/ Please select only one (1) Adult Shirt size:
S M L XL 2XL

St. Joseph College, Rensselaer……July 17-22

Payment – Mailing – Submission Instructions
Make Checks & Money Orders Payable to: Indiana Troopers Youth Service (ITYS)
Mail to: Indiana Troopers Youth Services (ITYS) 8660 East 21St Street, Indianapolis, Indiana 46219

Check or money orders that are returned Invalid/Insufficient will result in the application being returned!
If you fill this application on-line and email it to you will need to submit your payment on our PayPal payment option. There is a $5.00 non-refundable fee incurred when paying with Paypal. Please indicate in the notes of Paypal your child’s name and camp they are attending. If you would need to submit the application on-line and mail the payment, please indicate your child’s name and what camp they are attending on the check. Please indicate the following:
Check if paid by PayPal Amount Partial Paid By:
Check # Amount:
Administration Only
Paid if Full Deposited Date: Sponsored By:
Entered / Notes:

Proceed to page 2

2016 INDIANA STATE POLICE CAMP MEDICAL/LIABILTIY FORM

ALL SUMMER CAMP APPLICANTS ARE REQUIRED TO FILL OUT THIS FORM

Camper Medical Information
Camper Name: Last First MI Date of Birth

Insurance Carrier Policy #

List ALL ALLERGIES & what should be given when allergic reaction occurs:
List ALL Medical Conditions:
List ALL Medications/Dosage/Times (ALL MEDICATIONS MUST BE PROVIDED IN THE ORIGINAL CONTAINERS):
Please Share with us any information about your Childs emotional or mental health that will aid us in their care while at camp. If there are any issues at home or additional stresses your child is enduring, please contact the Camp Director.
This information is required to be reviewed and initialed. Your initials are required to acknowledge and consent to these terms. If you do not wish to consent to a particular term please put an “x” in the box.
If your camper has a serious injury or illness and we are unable to reach you we need your permission for “EMERGENCY Treatment” or “Surgery” as recommended by the attending physician:
I/We give my permission for Emergency treatment or surgery if needed and as a Parent(s)/Guardian I assume all responsibility for any cost as a result of sickness or injury.
Addt:
The following concerns the distribution of medications that are listed above by the camp nurse/designee:
I/We, as Parent(s)/Guardian, give my permission for the camp nurse/designee for medical care, to give my child/ward his/her medication as listed and instructed above, pursuant to Indiana Code 16-36-1.

The following concerns allowing your child to attend and/or participate in an off-site field trip or special event – conducted by the Indiana State Police, an agency of the State of Indiana.
I/We, as Parent(s)/Guardian give my permission for my child to participate in ANY field trip or special event, Conducted by the State Police, an agency of the State of Indiana, that might require such child to be taken off the Indiana State Police Camp University or Camp premises.

The following concerns the use of your child’s likeness in camp promotional publications.
I/We, as Parent(s)/Guardian, give my permission for the use of my child’s likeness in camp promotional publications.

I/We, as Parent9s)/Guardian(s) do hereby release the State of Indiana, the Indiana State Police, and the Indiana Troopers Youth Services, Inc., its agents and employees from all actions, damages, claims or demands which I/We, my heirs, executors, administrators, or assigns may have against the above named agencies for all personal injuries known or unknown and injuries to property real or personal, caused by, or arising out of the above described activities or participation.
We, the Parent/Guardian, the undersigned, have read this release and understand all its terms, we execute voluntarily and with full knowledge of its significance, pursuant to Indiana Code 16-36-1.
Please Print a “Signed”copy of this waiver and bring it to Camp on the day of registration or be prepared to sign the emailed copy at registration.
Parent/Guardian Signature: Date