2022 Girls Teen Reach Adventure Camp Registration

Teen Reach Adventure Camp Registration
Teen Reach Adventure Camp (T.R.A.C.) is a positive, faith-based summer camp experience especially designed to ensure success for youth residing in foster care who have likely experienced abuse, abandonment or neglect.

Each three-day camp focuses on safety by providing a unique ratio of one counselor to every two campers. Rather than being co-ed, each camp is single-sex to promote a greater level of comfort between staff and attendees. Volunteers are vetted and trained, including a camp nurse and behavioral specialist who are available to meet the needs of campers.

Every youth is offered complete confidentiality. No volunteers will take photos, other than the camp photographer who will take pictures for individual camper photo albums. All T.R.A.C. promotional videos/pictures will be edited for confidentiality.

Campers explore the wilderness, enjoy waterfront activities, make crafts and participate in a low-level challenge course designed to build self-respect, teamwork, trust and communication while having fun. Through encouragement and quality time with each teen, volunteers at T.R.A.C. strive to give campers a sense of hope that the past doesn’t have to define the future.

If you have any questions please e-mail: Camp Director - Heather Lojeski - tracracine@gmail.com
Girls' Camp: Friday Oct 14, 2022 - Sunday Oct 16, 2022

(For ages 12-15 years old)

SECTION 1: Camper Information
Camper's Full Name *

First Name Middle Name Last Name
Preferred Name/Nickname
Leave Blank if same as above
Gender *

Female Male
Age *
Age at time of camp (12-15 years old)
Emotional Age *
Birth Date *

Month Day Year

Adult T-Shirt Size: *

	SMALL	MEDIUM	Large	XL	2XL	3XL
Shirt Size:

Shoe Size *
Shoe Size
Name of Teen's Case Worker (if applicable)

First Name Last Name
Case Worker's Phone Number

Area Code Phone Number
Case Worker's Email
example@example.com
Case Worker's Supervisor's Name

First Name Last Name
Supervisor's Phone

Area Code Phone Number
Supervisor's Email
example@example.com
Name of Person Teen Lives With *

First Name Last Name
Relationship to Teen *
Bio-Parent,Adoptive parent,Foster parent,Relative,etc.
Name of second adult/parent

First Name Last Name
Relationship to Teen
Bio-Parent,Adoptive parent,Foster parent,Relative,etc.
Home Phone

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Work Phone

Area Code Phone Number
Email *
example@example.com
Second Email/Work Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Length of Time teen has been in this Home *
Has teen attended For the Children (formerly Royal Family Kids) or Teen Reach Adventure Camp? *

Yes No
If Yes, Which One?

Racine Kenosha Other
Names & ages of other Foster Children living in this home:
Only if Applicable
Emergency Information
Emergency Contact's Name *

First Name Last Name
Phone Number *

Area Code Phone Number
Alt. Phone Number

Area Code Phone Number
This youth is approved to attend the T.R.A.C.life Mentoring program if one is operating in this area & is selected to be a participant. *

Yes No

SECTION 3: Medical History
Doctor's Name *
Facility Name *
Phone Number *

Area Code Phone Number
Health Insurance/ Medicaid *
Insurance Number *
Name of Counselor/Pshchologist
Counselor Phone Number

Area Code Phone Number
Date of last tetanus booster (TDAP)? *

Please answer Yes or No. *

	YES	NO
Allergic to Bee Stings?
Carries an Epi-Pen?
Seasonal Allergies?
Diabetic?
Asthma?
Is teen Pregnant?

Please list ANY known allergies, medical conditions (mental or physical), illnesses or surgeries treated by a doctor. *
Does teen have any physical disabilities or other limitations? Yes/No/Describe *
Please list ALL medications teen is taking AND what it is for. Medications MUST be in original prescription bottles from prescribing physician. THIS IS NOT THE TIME TO GIVE MEDICINE VACATIONS. *
Name, Taken for, Dosage/Amount, Time Given

SECTION 4: Emotional & Behavioral History

Indicate the degree to which the teen displays the following emotions/behaviors. Please answer honestly. Negative behaviors DO NOT disqualify a teen from attending camp. *

	OFTEN	SOMETIMES	NEVER
Aggression/Anger
Bedwetting
Biting
Eating Disorder
Hyperactive
Lying
Nightmares
Runs Away
Sexual Acting Out
Stealing
Withdrawn/Sad

Please explain any behaviors that occur often & describe how they are handled. *
How many times has the teen been moved in foster placement?
Explain any family circumstances that make camp especially important for this teen.

SECTION 5:Permission to administer first aid & over-the-counter medications.
I hereby give the Teen Reach Adventure Camp nurse permission to administer first aid and the following products according to manufacturer's instructions, or as otherwise specified.

I Trust the T.R.A.C. Nurse to use his/her best judgement as situaions arise, and if in doubt, he/she can call for verification.

Select YES or NO for the medications listed below. *

	YES	NO	Special Instructions
Sunscreen
Insect Repellant
Lip Balm
Rash Ointment
Tylenol/ Acetominaphin
Advil/ Ibuprofin
Antiseptic Ointment
Band-Aids
Anti-Itch Cream
Alcohol Wipes
Cough Syrup
Cough Drops
Decongestant
Antihistamine
Pepto-Bismal
Tums/Antacid
Melatonin (For Sleeping)
Other

List any special instructions for above medications.
LIABILITY RELEASE: Every precaution will be takento protect campers and volunteers from harm, but Teen Reach/DBA T.R.A.C./Teen Reach Adventure Camp is not liable for injuries/death that youth or volunteer staff may incur while camping or participating in T.R.A.C. activities. If he/she is injured, I have given medical information and permission to take him/her to a medical facility for proper care. All extension activities are included in the liability release. I release the local T.R.A.C./T.R.A.C. National/Teen Reach, Inc. from any liability surrounding any injuries/death to the camper and/or the camper's unborn child if the camper is pregnant.
Medical Release and Authorization

This health history is correct so far as I know, and the above-named minor, has permission to engage in all prescribed program activities. The undersigned does hereby authorize T.R.A.C., on behalf of the undersigned, to consent to an X-Ray, examination, anesthetic, medical, dental, or surgical diagnosisor treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician/surgeon, licensed under the provission of the Medicine Practice Act or any dentist licensed under the Dental Practice Act,whether such diagnosis or treatment is rendered at the office of said physican or dentist, at a hospital, at camp or elsewhere. This authorization will remain effective while the above minor is en route to and from or involved in or participating in any camp program, unless revoked in writing by the undersigned and delivered to the Camp Director. During camp, prescription medication will be administered to youth as directed by a physician. T.R.A.C. will do everything in its power to prevent incorrect medicine from being given. However, Teen Reach/DBA T.R.A.C./Teen Reach Adventure Camp, is not liable for incorrect medicine provided to us by the legal guardian, incorrect dosages given, nor is it liable for wrong labeling on medicine bottles. Legal guardians are responsible for checking in the correct medications, bottles, and dosages at the time of registration. This is not the time to give medication vacations to your teen.
Confirmation

As legal guardian of the above youth, I agree that all the information provided in this application is accurate. I also agree to both the medical and liability releases and the permission to administer first aid and over-the-counter medications as incdicated in Section 5 above.

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature of Legal Guardian (Parent/Foster/Adoptive/Relative, etc) *
Printed Name: *
First and Last
Signature of Case Worker (If necessary/applicable)
Printed Name:
First/Last Title
Enter a photo of FRONT of Health/Insurance Card
Enter a photo of BACK of Health/Insurance Card
Enter a photo of your teen. Please be sure it is one they like! It will be used as their photo id.
Should be Empty:

Teen Reach Adventure Camp Registration

Girls' Camp: Friday Oct 14, 2022 - Sunday Oct 16, 2022