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Camper Application
Camper Application
campers age 7-15
Applications received before April 1st:$25 registration fee. Applications received after April 1st: $35 registration fee. Applications not accepted after April 30th!!! Please contact info@gatewayhemophilia.org if unable to pay the registration fee due to a hardship.
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Camper's Last Name:
*
Camper's First Name:
*
Camper's Date of Birth
*
Date Format: MM slash DD slash YYYY
Age on June 3, 2020:
*
Gender assigned at birth
*
Male
Female
Do you identify as a different gender than you were assigned at birth?
*
Yes
No
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name of Parents or Guardian:
*
Phone #
*
*
Home
Work
Cell
Alternate Phone #
Home
Work
Cell
Phone #
Home
Work
Cell
Email address
*
In an emergency, notify the following people, listed in order of preference. Please include each parent or guardian on this list. If traveling/vacationing when your child is at camp, please indicate how we may be able to reach you:
Name
*
Relationship
*
Phone
*
*
Home
Work
Cell
Name of Second Emergency Contact Person
*
Relationship
*
Phone #
*
*
Home
Work
Cell
Name of Third Emergency Contact Person
Relationship
Phone
Home
Work
Cell
Transportation
Arrival at camp (12-2:30 p.m.) on 6/3/20:
*
I will bring my child to camp
I can give another child a ride
My child will ride with
Pick up from camp on 6/6/20 starting at 10:00 a.m. Awards begin at 10:30 a.m.
*
I will pick up my child
I am able to give another child a ride
Please help me find a ride for my child
My child will ride with
Camper’s T-Shirt Size:
*
Youth size 6/8
Youth size 10/12
Youth size 14/16
Adult S
Adult M
Adult L
Adult XL
Adult XXL
PARENT PROVIDED MEDICAL INFORMATION
The information on this form is to assist us in determining appropriate care for your camper.
Health history must be filled out by parents/guardians of minors or by adults over the age of 18.
Insurance Company
*
Policy #
*
Name of person who carries the plan
*
*Please email a photo of the front and back of the child's health insurance card to info@gatewayhemophilia.org.
Bleeding Disorder Diagnosis:
*
Factor VIII
Factor IX
vWD
Mild
Moderate
Severe
Other
Name of your bleeding disorder doctor (hematologist):
*
Bleeding Disorder Doctor's Phone #
*
Name of Factor/Medication or state n/a
*
Dose
Frequency
Who does the infusion:
*
Camper
Parent
Nurse
n/a
Other
List who other is
*
How is the infusion delivered:
*
Port
Peripheral
n/a
Are there any target joints?
*
Yes
No
If yes, please list target joints
ALLERGIES
*
No known allergies
The Camper has allergies & I will list below
Food
If Food Allergy: Reaction Treatment
Medication
If Medication Allergy: Reaction Treatment
My camper is allergic to:
Other
If Other Allergy: Reaction Treatment
DIETARY REQUIREMENTS
My camper eats a regular diet
Does NOT eat:
red meat
pork
dairy products
poultry
eggs
Lactose intolerant
Yes
No
Celiac disease
Yes
No
Any other dietary concerns? State n/a if no allergies.
*
Medication
*
This camper will not take any daily medications while attending camp.
This camper will take the following daily medications while at camp:
“Medication” is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies.
Please review camp instructions about required packaging/containers below.
Name of Medication
Date started
Reason for taking it
When it is given
Breakfast
Lunch
Dinner
Bedtime
Other
Amount or dose given
How it is given
Name of second Medication (if applicable)
Date started
Reason for taking it
When it is given
Breakfast
Lunch
Dinner
Bedtime
Other
Amount or dose given
How it is given
Name of third Medication (if applicable)
Date started
Reason for taking it
When it is given
Breakfast
Lunch
Dinner
Bedtime
Other
Amount or dose given
How it is given
The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.
Check the medications the camper should NOT be given
Acetaminophen (Tylenol)
Phenylephrine decongestant (Sudafed PE)
Antihistamine/allergy medicine
Diphenhydramine antihistamine/allergy medicine (Benadryl)
Ibuprofen (Advil, Motrin)
Pseudoephedrine decongestant (Sudafed)
Guaifenesin cough syrup (Robitussin)
Dextromethorphan cough syrup (Robitussin DM)
Sore throat spray
Lice shampoo or cream (Nix or Elimite)
Calamine lotion
Laxatives for constipation (Ex-Lax)
Generic cough drops
Antibiotic cream
Aloe
Bismuth subsalicylate for diarrhea (Kaopectate, Pepto Bismol)
IMPORTANT INFORMATION REGARDING MEDICATIONS TO BE TAKEN AT CAMP……
1. Any medication that your Medical Provider requires to be administered at camp must be in its original pharmacy container labeled with the name of the person, name of the medication, dosage, and the frequency of administration. Please send only the correct amount of medication.
2. All medicines are kept in the Health Center and administered by our nurses. The exceptions are: off-camp trips when staff give the medications under the direction of the nurse; asthma inhalers and epi-pens with the written authorization from your Health Care Provider for self-administration.
3. All medications should be picked up at the Health Center by a person age 18 or older before departing for home. All medications not picked up will be destroyed.
I give permission for my child to be given the Over-the-Counter medications listed on the previous page (or generic equivalent), if needed, while at Camp. Doses to be administered as per package directions. I have checked any medications I do not want my child to be given.
Signature
*
Please check any current health conditions requiring medication, treatment or special consideration while at camp:
Ear infections
Prosthesis
Heart problems
Headaches
Hearing impairment
Vision impairment or problems
Please provide details
IMMUNIZATION HISTORY: Has your child been immunized for any of the following?
*
My child has never been immunized
MMR (Measles, Mumps, Rubella)
Chicken Pox
Whooping Cough (Pertussis)/DTap/TdaP
Tetanus booster/DTaP/TdaP
Date of last Tetanus booster/DTaP/TdaP
*
CAMPER INFORMATION
Describe any restrictions regarding swimming:
Describe any difficulties your child is having now, physically or emotionally:
Describe your child’s special qualities (quiet, active, hobbies, interests, etc.):
Describe any bedtime or sleep habits (fear of dark, sleep walks, special pillow, bedding, bedwetting):
GHA, Cardinal Glennon HTC and St. Louis Children’s HTC agree that children with moderate to severe Hemophilia and other bleeding disorders should be treated with regular, scheduled infusions of factor (prophylaxis) while at camp, so that they can fully enjoy all camp activities without fear of bleeding episodes. It is our hope that campers will learn how to self-infuse at camp.
If your child does not currently self-infuse, may we have permission to help your child practice this skill while at camp?
*
Yes
No
Already Self Infuses
Parent initial
Initials
*
What have we forgotten to ask?
Please provide in the space below any additional information about the camper you think is important or may affect the camper’s ability to partake in camp programs. Please include any psychological or social issues.
Parent—please list what you hope your camper will learn/do at camp:
*
Camper—please list what you hope to learn and/or do at camp this year:
AGREEMENT, CONSENT, WAIVER AND RELEASE FORM
Please read this information completely before signing. Its effect is to release the Gateway Hemophilia Association (GHA) and Camp Wyman from any liability resulting from your participation in the program activity named above and waives all claims for damages or losses against the GHA and Camp Wyman.
In consideration of GHA making arrangements for and permitting and assisting me in participating in the above named program activities, I exercise my own free choice to participate voluntarily in activities, understand and assume all associated risks, and promise to take due care during such participation. I hereby release and discharge, indemnify and hold harmless GHA, Camp Wyman, and their member officers, agents, employees and any other persons or entities acting on their behalf, and the successors and assigns for any and all of the aforementioned persons and entities, against all claims, demands, costs and expenses, and causes of action whatsoever, either in law or equity, arising out of or in any way connected with any loss and/or bodily injury and/or disability, arising from my participation in the above named program.
I understand that infusion therapy will be provided as needed at camp. I understand that treatment for routine illness and acute bleeding episodes (DDAVP and concentrates) will be supervised by the medical/nursing staff. I understand it will be necessary for me to send factor concentrate and/or DDAVP to camp with my child. If a diagnostic procedure, hospitalization, or other specialized therapy is needed, the cost of such care is my responsibility. I give my authorization for the medical staff to administer medical care and administer routine medications to my child.
I agree to allow my child to participate in the educational portion of camp including general hemophilia/vWD/bleeding disorder information, home infusion therapy, and possibly HIV/AIDS discussion.
I understand that I am solely responsible for any costs arising out of any bodily injury and/or disability or property damage sustained through my/my child’s participation in normal or unusual acts associated with the above named program.
I believe that my child is in good health, and affirm that their participation in the above named program activities will in no way aggravate any condition(s) present. If in doubt, I will seek further medical advice.
The undersigned does consent that photographs, video or motion pictures may be taken of the named applicant during the camp period, and that said photographs, video or motion pictures may be published in newspapers, magazines, television, publicity releases and/or other media, or program presentations by GHA.
The undersigned, in case of emergency and in the event the undersigned cannot be reached by telephone, does hereby give permission for medical treatment by a physician or hospital selected by the medical staff, camp directors, camp volunteers, GHA volunteers and others. Such permission shall include any and all medical treatment which is necessary or desirable in the absolute discretion of any such physician or hospital. This medical care shall include, but is not limited to, examinations, treatments, immunizations, injections, anesthesia, surgery, and other procedures, etc.
I have had sufficient time to review and seek explanation of the provisions contained above, have carefully read them, understand them fully, and agree to be bound by them. After careful deliberation, I voluntarily give my consent and agree to this Release, Assumption of Risk and Waiver.
Camp Activity Policy Each camper will be given the opportunity to participate in daily camp activities. Parents or guardians may indicate exclusions below if they do not want their child to participate in certain events.
Exclusions:
With the understanding that GHA will make every reasonable effort to prevent accidents, injuries, or other mishaps, I acknowledge the following: The undersigned does hereby agree to allow participation of applicant in all camp activities (except those restricted) The undersigned gives permission for the applicant to ride in vehicles operated or leased by the GHA.
The undersigned recognizes the right of the Camp Director, in his/her absolute discretion, to terminate a camper’s stay at any time due to disciplinary or medical actions which might jeopardize the campers or others health and safety at camp or camp property. The undersigned further agrees to pick up the camper immediately upon being notified of such termination. (Parents: Please discuss this behavioral contract with your child.) The undersigned agrees not to send the applicant to GHA if he or she has been exposed to a contagious disease within three (3) weeks of the starting date of camp, and to notify GHA if this situation arises. CONSENT TO RELEASE HEALTH INFORMATION UNDER HIPAA ACT
I understand and acknowledge the following: • That Camp Notaclotamongus is a medically based program sponsored by the Gateway Hemophilia Association • That camp is conducted by volunteers • That the information submitted on registration forms may contain health information about my child • That the protected health information can be used and disclosed to healthcare organizations for the purpose of treatment, healthcare operations and payment for medical treatment while my child attends camp • That camp volunteers of the Gateway Hemophilia Association may have access to information contained in the healthcare record or camp registration forms, as needed, in order to conduct the camp program
If someone other than the undersigned is to pick up the applicant at the end of the camp session, such person must present written authorization from the undersigned. I do hereby authorize
I have hereunto executed this Agreement, Consent & Release on this date:
Initials
*
Camp Notaclotamongus - Personal Behavior Contract
We are glad you have chosen to attend Camp Notaclotamongus this year! Camp life offers many unique opportunities and experiences for you and your fellow campers. We hope you make new friends, learn a lot, and have a great time! At Camp Notaclotamongus we expect campers and volunteers to encourage, support, and show respect toward one another. Each person at camp has a responsibility to make camp life positive and enjoyable. We expect all campers to follow the behavior expectations outlined below.
Behavior Expectations
1. Campers will treat everyone in the camp community with respect at all times and show respect for others’ personal belongings, privacy, and feelings. 2. Campers will remain with their counselors, follow directions, and abide by camp rules. 3. Campers will not be involved with smoking, alcohol use, illegal drugs, weapons, vandalism, theft, or any other illegal behavior. 4. Campers will use appropriate language; profanity will not be tolerated. 5. Campers will remain in camp unless on an escorted approved camp activity or for a medical emergency that requires transportation to an outside medical facility. 6. Campers will respect the camp facility and its equipment. Campers will be responsible for all damage due to negligence or intentional vandalism. 7. Campers will sleep in their assigned cabins each night.
Consequences
If a camper chooses not to follow the previously listed behavioral expectations, the following consequences may be issued depending on the severity of the situation. 1. Counselors will discuss the behavior with the camper. 2. Camper will be given a “time out” or not allowed to participate in a subsequent activity. 3. Camp Director will be notified and address the behavior with the camper. 4. Parents/Guardian will be contacted by the child and/or camp staff to discuss behavior. 5. Camper will be dismissed from camp. Parent/Guardian will need to pick up the camper.
I have read and understand the Camp Notaclotamongus Personal Behavior Contract and have discussed it with my child. I agree to support the behaviors and consequences listed above.
Date
*
Date Format: MM slash DD slash YYYY
Parent/Guardian Signature
*
Total $25