• 2021 Chicana In Nature Summer Day Camp Parental Release/Medical Forms/Code of Conduct

    Step 1: Complete this online form. You will need the camper present for the Code of Conduct section. Step 2: When you receive the email confirmation, forward that email to Susana Cruz, Chicana In Nature at scruz@chicanainnature.com

  • General Information

  • Male/Female*

  • Which week is your child attending?*

  • Parental Consent

  • The Undersigned, Being a Parent or Guardian of the above named minor releases Chicana In Nature, its representatives, agents, servants, and employees from liability for any injury to said minor, resulting from any cause whatsoever occurring to said minor at any time while attending Chicana In Nature Summer Day Camp, including travel to and from camp and any field trips, excepting only injury or damage resulting from willful acts of such representatives, agents, servants and employees. Chicana In Nature is also released of any expenses resulting from the injury.

    Your child will have the opportunity to participate in adventure activities, including but not limited to hiking, survival skills, water activities, climbing rocks, and outdoor cooking.  Chicana In Nature will provide trained staff who will conduct these activities in the safest manner possible. 

    Campers and parents are expected to be familiar with all camp policies.  To protect the safety of all campers, Chicana In Nature has no-tolerance policies that could immediately result in campers being sent home.  These policies include but are not limited to:

    1.      Use of violence or possession of weapons

    2.      Use of alcohol or drugs

    3.      Entering the restroom of the opposite sex

    4.      Disrespect of nature and anyone representing Chicana In Nature

    Parents or guardians of campers who violate policies will be notified to pick up their child. 

    During the week of camp, we will be taking pictures of the team and campers that will be used in the Week-in-Review slide show and for camp promotional material. Please contact Susana Cruz, scruz@chicanainnature.com if you have a need for exclusion.

    Chicana In Nature will have certified staff trained in First Aid & CPR on site that will treat for basic injuries and illnesses. Campers may be sent to a local hospital or physician if needed. Medical fees will be the responsibility of the patient, parent, or guardian.

  • Date of Signature*
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  • Camper Medical Information

  • Camper Date of Birth*
     - -
  • Do you have Health Insurance coverage for the camper?*
  • Does the camper have any allergies?*
  • Does the camper have an epi-pen? If so, they must keep it with them at all times!
  • Does the camper have any special food restrictions?*
  • Does the camper take any medications they will take during the week of camp?*

  • IMPORTANT: All medications must be in the original package (daily sorters/pill keepers are not permitted.)

    Please only send enough medication for the week of camp.

  • Has the the camper been diagnosed with asthma by a physician?*

  • IMPORTANT: If your child has been diagnosed with asthma by a physician and has medication including tablets, nebulizers, or inhalers, they MUST bring such treatment wtih them to camp or they will not be allowed to stay at camp!

     

    If your child has an inhaler, they must keep it with them at ALL TIMES during camp!

  • Does the camper have any other significant health history (heart condition, diabetes, any injury) or does the camper have any restrictions/medical conditions that the nurse needs to be aware of?*

  • Over the Counter Medications Permitted

    Please select Yes or No to the following medications your child may or may not be given at camp

  • May we give your child...

  • Tylenol?*
  • Ibuprofen?*
  • Pepto Bismol?*
  • Tums?*
  • Claritin?*
  • Benadryl?*
  • Maalox?*
  • Immodium?*
  • Tussin Cough Syrup?*
  • Glucose Tabs?*
  • Visine?*
  • Neosporin?*
  • Polysporin?*
  • Hydrocortisone Cream?*
  • Mucinex?*
  • Milk of Magnesia?*
  • Zantac?*
  • Midol?*
  • GasX?*
  • Orajel?*
  • Ducolax?*
  • Aleve?*
  • OTC Ear Drops?*
  • Campho-Phenique?*

  • Emergency Contacts

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  • Medical Information Signature

  • I have read and understand the statements in this release form.  I understand that should a health problem arise, I will be notified but if I cannot be reached by telephone I consent to emergency medical treatment, which may include surgery for my child as deemed necessary by competent medical personnel.  I also consent to the release of information for insurance purposes. 

  • Date of Signature*
     - -

  • Camper Code of Conduct

    This section must be completed by both the camper and a Parent/Guardian. Please read this section together.

  • Camper: If you agree and are willing to comply with all of the expectations of the Code of Conduct and Summer Day Camp Program, please sign at the bottom of the page.

    Parent/Guardian: Please sign the bottom of this form to show your intent to support the implementation of this Code of Conduct in regards to your child.

  • As a camper attending Chicana In Nature Summer Day Camp, I agree that:

    • I understand that I am attending a Chicana In Nature Summer Day Camp and will conduct myself in a manner that positively represents me, my family, my community, and Chicana In Nature. 
    • I understand that Chicana In Nature Summer Day Camp policies apply athe strictest rule will apply. 
    • I will participate in the camp program, display a positive attitude, and conduct myself appropriately at all times.
    • I will respect all campers, directors, staff, facilities, and nature. I will follow instructions from all adults and camp staff.
    • I will not use a cell phone during camp programs and activities, unless authorized to do so.
    • I will follow the dress code.
    • I will not enter a restrooms of the opposite sex.
    • I will not enter any other buildings that I am not assigned to.
    • I will not bring highly valuable items to camp.  If I do bring valuables, I accept full responsibility for those items.
    • I will not use language or behavior that is obscene, violent, or racially or sexually inappropriate.
    • I will not possess or use tobacco products, alcohol and/or drugs.
    • I will not possess or use firearms, weapons, pocket knives and/or firecrackers.
    • I will not bring skateboards, scooters, or roller blades.
    • I will respect camp property by keeping the facilities clean, not creating graffiti, and not using items such as water balloons, shaving cream, and toilet paper for destructive purposes. I accept responsibility for damages I cause. 

    I understand that failure to meet with these standards will result in these steps:

    1. I will call my parents/guardians and report my conduct not in compliance with these guidelines.
    2. At the Director’s discretion, this may result in my parents/guardians arranging transportation home.
    3. My parents/guardians will be billed for damages that I cause.

    I also understand that if I fail to follow no-tolerance policies, including but not limited to use of violence or possession of weapons, use of alcohol or drugs, entering the restroom of the opposite sex, or harassment of another camper or staff, then the following steps may be taken:

    1. I will be removed from the facilities.
    2. Law enforcement will be contacted. 
    3. I will be suspended from all activities with Chicana In Nature for up to 18 months.

  • Student Commitment:

    I have read and understand the Code of Conduct above. I agree to abide by it for the safety and enjoyment of myself and of other campers. I understand the consequences of failing to meet these guidelines.

  • Date of Signature*
     - -
  • Should be Empty: