ICOE Summer Camp 2023 Registration Form

Sierra Adventure Summer Camp 2023!

At the Sierra Adventure Center/Bernasconi Center in Big Pine
Open to Inyo County Schools Students Entering 6th, 7th, or 8th grades in the Fall of 2023

(Currently in grade 5, 6, or 7)
Week Attending*

Boys' Camp: June 19-23Girls' Camp: June 26-30
The Boys' Week is FULL - but please add your camper to the waitlist and I will contact you if any space opens up!
WAITLIST BOYS' WEEK*

Boys' Camp: June 19-23
The Girls' Week is FULL - but please add your camper to the waitlist and I will contact you if any space opens up!
WAITLIST GIRLS' WEEK*

Girls' Camp: June 26-30
Camper Name
First Name*
Last Name*
Camper's Information
Address*
City*
State*
Zip*
Home Phone*
Birth Date*

MonthDayYear
CURRENT Grade*
Click to choose grade level
School attending*
Click to choose school
Cabin Buddy

List first and second choice, not all requests are guaranteed, but we'll try!
Cabin Buddy #1
Cabin Buddy #2
List any campers your child should NOT be in the same group with.
Are there any special considerations or situations that we should be aware of?
Parent or Legal Guardian Information
Parent/Legal Guardian*
Relation*
Preferred Phone*
Preferred phone Type
Other Phone
Other Phone Type
Email
example@example.com
Parent /Legal Guardian 2
Relation 2
Preferred Phone 2
Preferred phone 2 Type
Other Phone 2
Other phone 2 Type
Email 2
example@example.com
Emergency Contact Name (in case parent or guardian is not available)*
Emergency Number*
2nd Emergency Contact Name (if first emergency contact is not avaliable)
Emergency Number #2
Health Information

We will contact the parent or guardian as soon as possible in the event of a serious accident or injury. Please bring all medication in the ORIGINAL CONTAINER or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must be in that camper's name and the correct dosage.
I understand my camper must be free from any infectious symptoms to attend camp.*

Yes
Comments
Approximate year of last tetanus shot*
All fields are required below. If nothing applies, please put "NONE" in the box. Thanks.
Any activity the camper should be restricted from?*
List any physical, mental or other condition that may require special attention or medication while at camp (such as asthma, diabetes, seisures, hearing or vision loss, etc). Please specify and share accomodations needed.*
List any past medical treatment that would be helpful for us to know.*
Any special diet needs that we should know about? Please explain.*
List any allergies (eg: bees, other insects, peanuts, dairy, other foods or substances)*
Are any of the above allergies LIFE THREATENING?

YESNO
Does camper have an EPI-PEN? If so, they must keep it with them at all times!*

YesNo
If your child uses an epi-pen, you will need to have the self-administration sections of the “Request for Administration of Medication at Summer Camp” form (see below) completed and signed by your child’s Health Care Provider
Parents will be notified of any illness or injury to their child and appropriate care will be given. In the event of an emergency in which I cannot immediately be reached, I authorize medical and/or surgical care for my child while he/she is attending the Inyo County Office of Education Program.*

Yes
Medications at Camp

ALL medications MUST be turned in to the director except rescue inhalers and epi-pens. Bring all medication in original containers. Label and put ALL medications (including over the counter (OTC) medications) in a baggie labeled with your child's name, and include instructions on administration. If prescriptions are included, you MUST fill out a Request for Administration of Medication (below) and have a health care provider's signature. Please do NOT pack any medications, even OTC medications, in your child’s luggage.
List ALL medications bringing to camp, both prescribed and over the counter. *
Does camper have an INHALER? If so, they must keep it with them at all times!*

YesNo
If your child uses an inhaler, you will need to have the self-administration sections of the “Request for Administration of Medication at Summer Camp” form (see below) completed and signed by your child’s Health Care Provider
Camper's Health Care Provider
Over the Counter (OTC) Medications at Camp

Please check all OTC medications you will allow us to give your camper if needed. We have these available for minor issues such as headaches, sunburns, insect bites, etc. If you do not check them, we will need to call and ask your permission every time, and this may be difficult. ** Whenever one of the oral medications is administered to your child, you will be notified at the earliest practical time afterward. The oral medications will be given in dosages and form appropriate for your child’s age and weight, as per the manufacturer’s recommendations.
Check medications that you GIVE PERMISSION for us to give your child on an as-needed basis:

** Acetaminophen (Tylenol or generic) tablets or children’s liquid, for minor pain relief**Ibuprofen (Advil, Motrin, or generic) tablets or children’s liquid, for minor pain and inflammation**Benadryl or generic tablets or liquid, as antihistamine for allergic reactions**Pepto Bismol or generic (Bismuth subsalicylate) liquid or tablets, for upset stomach/diarrhea**Tums or generic (Calcium carbonate), chewable antacid for indigestionRicola (or similar) Throat Lozenges (Menthol), for sore/scratchy throat reliefSting-Eze (or similar) topical (Benzocaine), for mosquito bite/insect sting reliefAloe Vera topical gel or lotion, for sunburn reliefNeosporin or generic (Neomycin/polymyxin B/bacitracin) topical, for minor cuts and scrapesOther - bring to camp
Special Instructions or comments for OTC Medications
Your child's approximate weight for medication dosage in case of need
Prescription Medications at Camp

Please download and send or print and take to your health care provider to fill out and sign for ANY prescription medication needed at camp, including inhalers and epi-pens. Upload or email form, or bring paper form to camp. You MUST have this form signed by a health care provider before coming to camp. These forms will also be available to pick up at your child's school and at the ICOE office in Bishop.
My child takes prescription medications that I will bring to camp (labeled in original containers as specified above) with the form below signed by my child's health care provider.

YesNo
If your child requires an injectable drug, the child must have the ability to administer it to him/herself. Our staff cannot administer injectable drugs except in an emergency (glucagon, Epi-pens).
Download Medical Form here if needed:
If you have a problem printing the form - please indicate in the field and you will be contacted - there should be paper forms available at your child's school.
Upload signed Request for Administration of Medication form here

Click button above to choose signed form to upload
Cancelof
Discipline Policy at Summer Camp
A Three-Step Discipline policy is used at Summer Camp.
1. *On the first offense, the student will have a conference with his or her instructor.
2. On the second offense, the student and director will call you to discuss the misbehavior.
3. On the third offense, the student will call you to tell you that you need to take them home.
*Students may be sent home on the first offense for behavior that endangers other students or staff.
I have read and understood the above consequences for breaking the rules established at the Summer Camp, and understand that I will be required to transport my child home immediately should the Camp Director determine it is necessary.*

Yes
Camper Release
Camper Release (List anyone your camper is allowed be released to, including parents, other relatives, family friends, etc.)*
Disallowed Camper Release (List anyone your camper should NOT be released to or write "none"). *
QUESTIONS? Contact Camp Director Maggie Riley at 760-873-3262x2131 or email mriley@inyocoe.org (best).
Email Confirmation
Parent Email (confirmation will be sent by email to this address)*
example@example.com
Review and Submit

Be certain to enter your email address correctly above to receive confirmation
By initialing, and hitting submit, I agree that I am the parent or legal guardian of the above-named camper, and am over the age of 18.

In case of a medical emergency or general medical care, I give consent for medical treatment for the above-named camper by authorized personnel. The camp carries secondary insurance.

I understand that the above named camper will only be released to the names listed above, and an update may be done at registration.

I certify that my child has my permission to attend camp and participate in all activities.

I authorize the Inyo County Office of Education to use my camper's picture, testimony, and video in any promotional material (web, print, or media)

I understand that if my child is showing any symptoms of infectious disease on the first day of camp, I will keep them home until the symptoms have cleared.
Electronic signature, please initial*
Suggested Payment / Donation

There is NO CHARGE for Summer Camp, but cost to put on our Summer Camp is around $300 per camper, so in order to help offset costs for school districts, we are requesting donations of $30 per camper for Summer Camp this year IF you are able to help. However, if you are unable to afford this, simply check the "scholarship" option below. If you'd like to donate in any amount to help pay for other campers and offset costs for school districts, we thank you and we will provide a receipt. You can donate via PayPal below or bring a check (payable to Inyo County Office of Education) to camp to give the director upon check-in.
Scholarships

If you cannot afford to pay, choose the scholarship scholarship option to use donated funds - no child will be refused if unable to pay!
Payment, Donation, or Scholarship Options (choose as many as apply)*

Paying $30 for 1 CamperOther donation amountI need a scholarship for my CamperI will pay with a check that I will bring to camp when we check inI will Pay with PayPal (below)
PayPal

Skip if not using PayPal - go to Submit at bottom of form
PayPal Donation amount:

prevnext( X )
USDUse PayPal to help pay for Summer Camp for your own or other campers

Pay with PayPal

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Sierra Adventure Summer Camp 2023!

Open to Inyo County Schools Students Entering 6th, 7th, or 8th grades in the Fall of 2023

Camper Name

Camper's Information

Cabin Buddy

Parent or Legal Guardian Information

Health Information

Medications at Camp

Over the Counter (OTC) Medications at Camp

Prescription Medications at Camp

Discipline Policy at Summer Camp

Camper Release

Email Confirmation

Review and Submit

Suggested Payment / Donation

Scholarships

PayPal