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:

Transportation

Arrival at camp (12-2:30 p.m.) on 6/5/19:

Pick up from camp on 6/8/19 starting at 10:00 a.m. Awards begin at 10:30 a.m.

Camper’s T-Shirt Size:

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.

*Please email a photo of the front and back of the child's health insurance card to info@gatewayhemophilia.org.

ALLERGIES

DIETARY REQUIREMENTS

“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.

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

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.

CAMPER INFORMATION

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.

What have we forgotten to ask?

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.

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:

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.

Total $25