Summer 2023 Camp Cell-A-Bration Registration Form

Summer 2023 Camp Cell-A-Bration Registration

Sunday, August 06, 2023 - Friday, August 11, 2023 Camp For All, Burton, TX
It's a Sickle Cell-A-Bration of Life!

Camp Cell-A-Bration is a week-long camp for kids aged 6-14 with sickle cell disease. Many of our children with sickle cell disease have suffered strokes, jaundice, pain crisis, chronic blood transfusions, surgeries, acute chest syndrome, and damage to their internal organs. Although these children battle this life-threatening disease every day, we want to make sure they enjoy being KIDS!
Registration/Application Fee

Camp Cell-A-Bration is FREE for children with Sickle Cell Disease!

Early Registration: $40 non-refundable application fee must be paid with your application before June 2, 2023.

Late Registration: $50 non-refundable application fee must be paid with your application.

***Limited scholarships available upon request
Important Information / Need Help?

Application and Supporting Documents (physical exam) Due By: Friday, July 7, 2023.

This application must be completed and submitted online. The application will take 20-25 minutes, one application per child. Your childs application will be considered incomplete, if agency does not receive supporting documents by the deadline date and placed on a waitlist.

If you have questions about this application, or need further assistance, please contact the Sickle Cell Association of Texas Marc Thomas Foundation at (512) 458-9767 or send an email to info@sicklecelltx.org.
Camper Information
Camper Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Age at Camp*
Gender*

MaleFemale
Camper Shirt Size*

Youth SYouth MYouth LAdult SAdult MAdult L
Please select one location for camper to be dropped off / picked up:*
Camper Physician and/or Clinic Information*
Name of Physician/Clinic
Physician/Clinic Contact Information*
Phone Number
Camper Medical Insurance Information*
Name of Insurance Carrier
*
Insurance Policy/Group ID Number
Please upload a copy of your childs insurance card:

Cancelof
Please upload a picture of your camper:*

Cancelof
Parent/Guardian Information
Parent/Guardian Name*

First NameLast Name
Relationship to Camper*
Cell Number*
Work Number
E-mail*
example@example.com
Emergency Contact Information

I authorize the following individual to be contacted and I give my permission to turn my child over to the individual, if for any reason my child has to leave camp and I cannot be reached.
Emergency Contact 1*

First NameLast Name
Relationship to Camper*
Phone Number*
Alt. Phone Number
Emergency Contact 2*

First NameLast Name
Relationship to Camper*
Phone Number*
Please enter a valid phone number.
Alt. Phone Number
Please enter a valid phone number.
All About The Camper

Please share your childs interest or story, so that our camp team can understand and make sure your child has a safe, healthy, and fun time at camp. This information is extremely helpful! Please fill this out to the best of your ability and write as much as you'd like!
Has your child attended Camp Cell-A-Bration in the past:

YesNo
Has your child ever been away from home for more than five (5) days:

YesNo
How does your child function in large groups:
What can camp staff/counselor do to calm your child, if he/she gets upset:
Please share strengths and positive things about your child:
Please share your child's interests:
Please share a brief description of your child's personality (outgoing, shy, easily frustrated):
When upset, how does your child show aggression towards others:
In what situations does your child feel least comfortable:
Please share your childs fears or unusual behaviors (if any):
What kind of challenges (if any) may your child's Camp Counselor encounter from your child:
Any additional information you'd like us to know about your child:
Is your child emotionally sensitive:

YesNo
Does your child tend to (check all that apply):

WanderDaydreamUse Foul LanguageRunawayNoneOther
If other, please explain below:
Camper Medical History
Can your child participate in swimming activities:

YesNo
Does your child know how to swim:

YesNo
Does your child have a time limit in the water:

YesNo
If Yes, please explain below:
Does your child have tubes in his/her ears:

YesNo
Does your child use a prescribed inhaler:

YesNo
If yes, please explain any instructions below:
Is your child immunizations up-to-date including, pneumo/meningococcal vaccine:

YesNo
Does your child regularly use oxygen, breathing machines:

YesNo
If yes, please describe below:
Has your daugther started her period:

YesNo
Does your daughter have menstrual cramps:

YesNo
If Yes, does your daughter take medication? Please list the medication below:
What are your child's sleeping habits (check all that apply):

Average SleeperHeavy SleeperLight SleeperSleepwalksBed WetsNightmaresNone
Does your child have (or ever had) any of the following chronic illness, or medical conditions (please select all that apply):

Kidney ProblemsMonthly TransfusionsSpeech ProblemsHeadachesBreathing ProblemsAbnormal TCDAllergy ShotsHearing ProblemsSkin/Staph InfectionsStrokeAsthmaVision ProblemsADD or HyperactivityHormone ProblemsImmune Problems2 or more admissions per yearVision ProblemsAutismAnxietyEmotional StressNoneOther
If other, or any of the above medical conditions are present, please describe below:
Is your child allergic to anything (medications/food/insects/animals/ect.):

YesNo
If yes, please describe and list the allergy and reaction below:
Medication Release
The below medications are keep on hand during camp. Please select which medications you are comfortable with our med staff giving your child. All medications are given according to instructions found on the medication and per medical staff protocol.*

Acetaminophen (Tylenol)Antihistamine/Allergy MedicineAloe Vera Gel/LotionIbuprofen (Advil, Motrin)Robitussin or EquivalentCalamine LotionSudafed PERobitussin DM or EquivalentAntibiotic CreamBenadryl CreamTums/AntacidsSwimmer's Ear DropsSore Throat SprayLaxatives for ConstipationEye Drops (Visine or Equivalent)Heating Pads

List all prescription medications and over the counter medications taken regularly by your child. (Including vitamins, and over the counter medications that your child will take during camp.)*

	Name of Medication	Bring to Camp?	Frequency (per day)	Times Given (morning, afternoon, night)	Dose (tablets, spoonfuls, TBS, TSP)
Medication 1
Medication 2
Medicaiton 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication10

Camper Physical Exam Form
***Please download and complete the below physical exam form***

Have your child's Doctor or Nurse fax or email a completed Camp Cell-A-Bration Physician History & Physical Exam Form.

Our Austin (main) fax number is (512) 233-5869, Houston fax number is (713) 538-8850 and San Antonio fax number is (210) 634-2504. Please feel free to fax to either location.

Main Email: info@sicklecelltx.org
***Please download and complete the below physical exam form***

Camp For All-Liability Form

Please copy and past the link below on a different tab/browser to complete.
Did you complete the Camp For All Liability form:*

YesNo
Camper Behavior, Transportaion, Photography & Waiver Form

I authorize Camp Cell-A-Bration staff to provide any and all necessary care for the child named above. I further authorize the Summer Camp Director, the Executive Director or designee of the Sickle Cell Association of Texas Marc Thomas Foundation (SCAMTF) to seclude this child until their parent or guardians pick them up for any behavior that may be inappropriate or dangerous for that child or other children at the camp.

I consent to emergency treatments for the child named above, while in the care of the Sickle Cell Association Summer Camp staff. I understand that emergency treatments and care will be provided at the camp, or at the nearest appropriate health care facility. I also consent to emergency transportation of this child. However, payment of any emergency treatments for my child is my responsibility.

I authorize and grant permission for my child to be photographed, videotaped, and recorded including the use of his or her name, for use by the SCAMTF.

I hereby agree to hold harmless the SCAMTF, employees, camp staff and others involved from any and all liability of whatsoever nature and from injuries, sickness or other damages suffered by us or the camper during his/her stay at Camp For All and by any act or omission of said organization, employees, camp staff or others involved.

I hereby consent and agree to allow my child to be transported by the SCAMTF and/or transportation company, to and from Camp Cell-A-Bration. I hereby release, waive, discharge, covenant not to sue, and agree to HOLD HARMLESS for any and all purposes SCAMTF, their members, officers, servants, agents, volunteers, or employees from any and all liabilities, claims, demands, injuries or damages, including court costs and attorney’s fees and expenses, that may be sustained by my child while traveling to and from Camp Cell-A- Bration and Camp Cell-A-Bration activities.

My signature acknowledges that I have been given the opportunity to ask questions about this form and its importance.
CAMP CELL-A-BRATION ZERO-TOLERANCE POLICY AND AGREEMENT

The following will NOT be tolerated by:
- Rough Housing
- Disrespecting staff, counselors, camp staff and other campers (this also applies to parents of campers)
- Not following directions, not listening, bullying other campers and staff
- Profanity abuse or threatening language or behavior
- Gang related clothing or paraphernalia
- Physical contact, fighting, assault and/or violence
- Taking or touching other’s property without permission
- Separating from the group
- Drugs or alcohol
- Weapons or firearms
- Violation of curfew
Camp Cell-A-Bration adheres to a strict Zero Tolerance Policy. Parents will be called immediately upon any infraction of the above listed camp guidelines. I understand that if I cannot be reached, the emergency contact listed on the camper’s application will be notified.
I, blanks* understand that I, the parent, will be responsible for any items that my child (camper), blank*,breaks or damages while at Camp Cell-A-Bration/Camp For All. I understand that if my child experiences a disciplinary problem (breaches the Zero Tolerance Agreement), he/she will be removed from their cabin and placed under strict supervision. Upon 2nd infraction, he/she will not be able to attend any of the regularly scheduled camp activities. If the child continues to cause problems and violates the Camp Guidelines, the child must be picked up by a parent or guardian and will not be able to participate in the following year’s Camp Cell-A-Bration. I also understand that my child may be immediately dismissed from Camp for a violation of the Zero Tolerance policy if the Camp Director deems it necessary.

Additionally, I understand that completing this application does not nessarily mean my child will be accepted into camp. Factors including funding, past behaviors, certain circumstances and/or space will determine if my child will be accepted.

I acknowledge and understand this agreement between the Sickle Cell Association of Texas Marc Thomas Foundation, my child and myself.
Camp Cell-A-Bration Photography/Video Release Form

I, blanks* give permission for the Sickle Cell Association of Texas Marc Thomas Foundation (SCAMTF) to take and use any photographs/videos of blank*, including the use of his/her name, for general promotional purposes now or in the future in keeping with the general goals of the agency.

I agree that photographs and/or videos take of my child, including transparencies, negatives, prints, electronic versions and products thereof, may be used by the SCAMTF in a legitimate manner for educational program development and/or promotion including but not limited to fundraising, website usage, brochures, pamphlets, flyers, presentations, outreach, advocacy, education, sponsorship information, media and literature. By signing this document/application, I agree that I am granting the SCAMTF the right to exhibit the photo/video images for the aforementioned purposes.
Camp Cell-A-Bration Camper General Liability Release, Waiver, Indemnification And Agreement Not To Sue

1. PARTICIPATION CONSENT: I, the undersigned parent/legal guardian of camper authorize said child’s participation in CAMP CELL-A-BRATION (“CAMP”), including all related activities. I fully understand all of the dangers, hazards and risk that are associated with and may occur as a result of my child’s participation in the CAMP and related activities. These activities include, but are not limited to, the activities of horseback riding, high and low elements ropes course, swimming, archery, riflery, sporting activities, canoeing, and other camp related activities. I understand that these activities are voluntary and I have familiarized myself with Camp Cell-A-Bration Program and activities at Camp For All in which my child will be participating. I understand that these dangers and risks may result in property damage and/or loss, impairment to health and well-being, and/or physical injury, including serious or even fatal injuries. I acknowledge that although Camp Cell-A-Bration and Camp For All have taken safety measures to minimize the risk of injury to camp participants, Camp Cell-A-Bration and Camp For All cannot insure or guarantee that the participants, equipment, premises or activities will be free of hazards, accidents or injuries. I recognize and have instructed my child in the importance of knowing and abiding by the rules, regulations, and procedures for Camp Cell-A-Bration at Camp For All. I also agree to inform Camp Cell-A-Bration of any activities in which my child may notparticipate.

2. EXCULPATORY AND INDEMNITY CLAUSE. In consideration of my child being permitted to participate in the CAMP (free of charge), I agree to assume full responsibility for all risks. I further agree to release, waive, agree to hold harmless and covenant not to sue the Camp Cell-A-Bration, and all purposes the Sickle Cell Association of Texas Marc Thomas Foundation a non-profit agency, and its board of directors, officers, agents, employees, volunteers, and Camp For All (referred to collectively as "Releasees"), from and against any and all liability, claims, demands, actions, causes of action, suits in equity, whatsoever arising out of or related to any loss, damage, loss of property, or injury, including fatal injuries along with court costs and attorney’s fees and expenses whether caused as a result of sole, joint or concurrent negligence, negligence per se, statutory fault or strict liability of releases or otherwise, that may be sustained by my child while participating in CAMP and CAMP related activities while in or upon the premises where the CAMP and related activities are being conducted or while being transported to, from or in connection with the CAMP. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct. I further agree to indemnify the Releasees from liability, claims, demands, actions, causes of action, or suits in equity arising out of loss, damage or injury that occurs as a result of my child’s negligent or intentional act or omission while participating in the CAMP and in related activities.

3. NO INSURANCE. I understand that Releasees may or may not maintain any insurance policy covering any circumstance arising from my child’s participation in CAMP or any event related to that participation. As such, I am aware that I should review my personal insurance coverage. CAMP and SCAMTF may not carry general liability insurance to cover claims arising from CAMP and CAMP activities so it seeks a waiver of claims as additional consideration for the right to participate so CAMP and the SCAMTF, can (a) provide the CAMP free of cost to most participants; and (b) to provide access to a greater number of participants by expending limited resources on program materials and activities rather than on liability insurance.

4. MEDICAL AUTHORIZATION, INDEMNITY FOR MEDICAL EXPENSES, and WAIVER. I understand Releasees cannot be expected to control all of the risks articulated in this form and Releasees need to respond to accidents and potential emergency situations. Therefore, I hereby give my consent for any medical treatment that may be required, as determined by a medical professional at an off-site medical facility or hospital, during my child’s participation in this activity with the understanding that the cost of any such treatment will be my responsibility. I agree to indemnify and hold harmless Releasees for any costs incurred to treat my child, even if Releasees has signed hospital documentation promising to pay for the treatment due to my inability to sign the documentation. I further agree to release, waive, discharge, covenant not to sue, and agree to hold harmless for any and all purposes, Releasees from any and all liabilities, claims, demands, injuries (including fatal injuries), or damages, including court costs and attorney ’s fees and expenses, that may be sustained by my child while receiving medical care or in deciding to seek medical care, including while traveling to and from a medical care facility, including injuries sustained as a result of sole, joint, or concurrent negligence, negligence per se, statutory fault, or strict liability of Releasees. I understand this waiver does not apply to injuries caused by intentional or grossly negligent conduct.

5. BINDS HEIRS. It is my express intent that this Release, Waiver, Indemnification and Agreement not to Sue shall bind myself, my child, the other members of my family and spouse, if I am living, and my estate, family, heirs, administrators, personal representatives, or assigns, if I am notliving.

6. AGREEMENT OF RELEASE AND VOLUNTARY SIGNATURE: In signing this Release, Waiver, Indemnification and Agreement not to Sue, I acknowledge and represent that I have carefully read the document and understand its contents and that I sign voluntary as my own free act and deed. CAMP and Releasees has not made and I have not relied on any oral representations, statements, or inducements apart from the terms contained in this agreement. I further state that I am at least eighteen (18) years of age and fully competent to sign; and that I have executed this Release for full, adequate, and complete consideration fully intending to be bound by the same.
PLEASE READ CAREFULLY BEFORE SIGNING

By signing below you agree to the terms of the Waiver, Indemnification and Agreement not to Sue and agree to follow all instructions and procedures in order to maintain safety while attending Camp Cell-A-Bration.

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.
Date*

MonthDayYear
Date
Signature*

Clear
Do you have the ability to pay the registration/application fee:*

YesNoNeed Scholarship

My Products

Early Registration Application Fee

$40.00

Total

$0.00

Credit Card Details
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Credit Card Number	Security Code
Card Expiration

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Summer 2023 Camp Cell-A-Bration Registration

Camper Information

All About The Camper

Camper Medical History

Medication Release

Camper Physical Exam Form

Camper Behavior, Transportaion, Photography & Waiver Form