2023 Chandler T.R.A.C. Camper Application

A Camp For Teens In Foster Care Ages 12-15

Boys Camp:	July 8th - 11th, 2023
Girls Camp:	July 13th – 16th, 2023

 

Please list ALL medications the teen is taking. Please include the following for each medication:

1. Name
2. Reason for taking it
3. Dosage / Amount
4. Times Given

NOTE: MEDICATIONS MUST BE IN ORIGINAL PRESCRIPTION BOTTLES FROM PRESCRIBING PHYSICIAN. THIS IS NOT THE TIME TO GIVE MEDICATION VACATIONS.

Permission to administer first aid & over-the-counter medications.

This information must be confirmed by and signed for by the legal guardian who signs this application, which will take place after the application is reviewed.

Please check YES or NO for the medications listed below, which after the application is signed, gives our Registered Nurse permission to administer the following products according to manufacturer's instructions, or as otherwise specified.

If you have any of the following, you can upload them now. If not, you will be able to get us the information later. Respond to your confirmation email or use one of the methods below to get the following to us:

1. Copy of health insurance card or information
2. A recent photo of the teen
3. Confirmation of application to AFFCF (if applicable; forwarding us the email confirmation to campers@chandlertrac.com is probably the easiest method)
4. $25 deposit (if applicable)
   This can either be mailed to the church at the address below, or you can use the general online camp donation form on our website at www.chandlertrac.com. If you use the use the online option, please email campers@chandlertrac.com to let us know you did so.

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Alternate ways to submit the information (please include teen's first and last name with any correspondence):

* Email campers@chandlertrac.com OR reply to your confirmation email.

* Text 480-220-4925 with picture of requested item.

* Mail: T.R.A.C. CrossRoads Nazarene Church 2950 West Ray Road Chandler, AZ 85224

* FAX: 480-722-0770 attn: Sandy Schaumburg

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By clicking the submit button, I agree to submit this form by electronic means and I agree to the terms and conditions.

I certify, under penalty of perjury, that my signature below signifies the information in this application is true and correct to the best of my knowledge.

You are signing this Application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Application. By signing this document electronically, you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a keypad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Chandler T.R.A.C., or in accessing or making any transaction regarding any agreement, acknowledgment, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforce-ability of your E-Signature or any resulting contract between you and the Chandler T.R.A.C.

I understand that I am not required to sign this form electronically and can request to sign a paper copy if I so choose.