Teen Camp Freedom Registration Form

Emergency Contact Information
Name of Parent / Guardian *

First NameLast Name
Relationship to Camper*
Cell Phone*
Please enter a valid phone number.
Email*
name@example.com
Second emergency contact*

First NameLast Name
Relationship to Camper*
Cell Phone*
Please enter a valid phone number.

Medical Information: Allergies
Does the camper have allergies? (Medication, environmental, food)*

YesNo
What is the camper allergic to?
Allergic reaction:
Recommended treatment:
Does the camper require an epi-pen?

YesNoOther

Medical Information: Neurologic
Does the camper have hydrocephalus or is prone to headaches or seizures?*

YesNo
Does the camper have a shunt?

YesNoOther
What type of shunt?
What symptoms are experienced if there are complications with the shunt?
Is there anything that may make the symptoms more likely to occur? (ex. lack of sleep, vigorous exercise, dehydration, loud noise)
How are headaches usually managed? (ex. advil/tylenol, nap, quiet time)
Is the camper subject to seizures?

YesNo
Frequency of seizures:
Duration of seizures:
Description of seizures:
Behaviour after seizures:
Recommended treatment:

Medical Information: Executive Functioning and Mental Health
Executive Functioning

Executive Function (EF) is an umbrella term which refers to a group of mental skills that enables individuals to regulate their behaviours and complete goal-directed activities. Experts vary in their opinion about how to precisely define EF. However, most agree that EF consists of three groups of skills that allow individuals to manage their thoughts, actions, and emotions in order to get things done.

Those skills groups are:

• Working memory

• Cognitive flexibility (or flexible thinking)

• Inhibitory control (including self-control)

Skills in each of those areas help people to:

• Pay attention

• Organize and plan

• Initiate tasks and stay focused on them

• Regulate their emotions

• Self-monitor or keep track of what they are doing
Does the camper have executive functioning concerns?*

YesNo
What executive functioning concerns does the camper have?
Does the camper have developmental delays?

YesNo
Does the camper have any mental health concerns?*

YesNo
What mental health concerns does the camper have?
If the camper were to have a mental health crisis (ex. anxiety attack) at camp, are there strategies that could be used to help them cope?

Medical Information: Orthopedic
Does the camper have orthopedic concerns?*

YesNo
Does the camper use any of the following?

BracesOrthoticsNone of the aboveOther
Should the camper be wearing the braces or orthotics continually or can they have them off for short periods of time?
Do the braces or orthotics need to be worn when the camper is physically active?

YesNoOther
When are shoes required? Can the camper go short periods of time without shoes on?*

Medical Information: Skin
Is the camper at risk for skin breakdown?*

YesNoOther
What strategies or supplies are used to prevent skin breakdown?
Please describe dressing change protocol and all supplies needed:
Does the camper currently have any active skin breakdown?*

YesNoOther
Will the camper require dressing changes at camp?

YesNo

Medical Information: Pain Control
Does the camper have pain control concerns?*

YesNo
Does the camper have any of the following?

Acute painChronic painNone of the aboveOther
Does the camper take any regular or as-needed pain medication?*
Does the camper use any non-medical ways to cope with pain? (ex. lying down, heat or ice packs)

Medical Information: Gynecological
Does the camper currently menstruate?

YesNoN/A
What assistance does the camper require with their periods?

Medical Information: Other
Does the camper have any of the following medical devices?

TracheotomyOxygenSuctionCPAP/Vent
Please describe how to best assist the camper with their medical device:
Reminder: Medications must be brought to Camp Freedom in original containers and all supplies need to be latex free.

Waivers
CHILD or DEPENDENT ADULT WAIVER

ASSUMPTION OF RISKS
I, the parent or guardian of the Participant, acknowledge that we are aware that participation in activities organized as part of the Spina Bifida and Hydrocephalus Association of Northern Alberta and Camp Freedom involve many risks, dangers, and hazards, including, but not limited to, risks, dangers, and hazards associated with traversing low rope courses, climbing, canoeing, swimming, encountering animals and wildlife, and changing weather conditions. I am aware of the risks, dangers, and hazards associated with such activities and I freely accept and fully assume all responsibility for all such risks, dangers, and hazards and the possibility of personal injury, death, property damage, or loss resulting from such activities.

RELEASE OF LIABILITY, WAIVER OF CLAIMS and INDEMNITY AGREEMENT

As the parent or guardian of the Participant, I freely consent to all such risks related to participation and fully assume all responsibility for the possibility and related costs of personal injury, death, disability, property damage or loss resulting thereof, howsoever caused, including negligence, with the sole exception being gross negligence on the part of Camp Freedom and Spina Bifida and Hydrocephalus Association of Northern Alberta, their members, agents, employees and directors (herein collectively called "Spina Bifida and Hydrocephalus Association of Northern Alberta Camp Freedom"). I further waive and release any and all claims that the Participant or I have or may have in the future, on my own behalf and on behalf of the Participant, against Spina Bifida and Hydrocephalus Association of Northern Alberta Camp Freedom as a result of the participation of the Participant at Spina Bifida and Hydrocephalus Association of Northern Alberta Camp Freedom. I also hold harmless and indemnify Spina Bifida and Hydrocephalus Association of Northern Alberta Camp Freedom from any and all liability for all personal injury, death, property damage, or loss to any third party resulting from the Participant’s participation in the programs run by Spina Bifida and Hydrocephalus Association of Northern Alberta Camp Freedom. This consent shall be effective and binding on the Participant, heirs, next of kin, executors and administrators of myself and the Participant, for the entirety of the year stated below.

I confirm that I have read and understood this Release of Liability, Waiver of Claims and Indemnity Agreement prior to signing it, and I am aware that by signing it I am waiving certain legal rights that I or my heirs, next of kin, executors, administrators, assigns and representatives may have against Spina Bifida and Hydrocephalus Association of Northern Alberta Camp Freedom.

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.
Electronic Signature of Parent or Guardian*
Please type your full legal name

Photo, Film, and Video Consent
The Spina Bifida and Hyrdrocephalus Association of Northern Alberta is a non-profit organization which relies heavily upon donations from private and corporate donors for its operations. If it were not for donations, Camp Freedom could not operate. Film and video presentations are often made to build awareness and to raise funds. Photo displays are used at various fairs and events to promote awareness of Camp Freedom, recruit staff and volunteers, and encourage campers. The funds raised through these means, along with the camp fees, make our camp programs possible.

PHOTO RELEASE

I hereby give my consent and authorization to Spina Bifida and Hyrdrocephalus Association of Northern Alberta to use pictures and video footage taken during the camper's time at camp for advertising purposes. For campers attending a camp through a partnering organization, this permission extends to that organization as well. No identifying names or details will be given.

AGREEMENT

By clicking either 'Agree' or 'I do not agree', you either grant permission or deny permission for photos or videos to be used for the aforementioned purposes.

*NB: The Spina Bifida and Hydrocephalus Association of Northern Alberta makes every effort to honour the wishes of parents/guardians/public trustees. In some cases, the camper may desire to have their photo taken by other campers. The SBHANA will not be able to control the taking or distribution of these photos.
Photo Release*

I agreeI do not agree

Medication Waiver
Medical information must be provided for the camper every year to attend camp. It is essential for the camp to have the camper's current medication and health information to ensure their safety and well-being while at camp.

Any information entered is the RESPONSIBILITY OF THE CAREGIVER to keep up-to-date. False information may result in a camper being removed from camp.

I/We (Parent, Guardian, or Applicant if the age of majority and own guardian) hereby give my/our consent and authorization for Applicant to be given such emergency medical and/or hospital care as may be deemed necessary by Camp Freedom medical authority, in the best interest of the Applicant while he/she may be attending camp. Every effort will be made to contact the primary contact person, and failing this, the alternate contact person referred to in the attached application form prior to obtaining emergency medical and/or hospital care for the Applicant and, if this is not possible, at the discretion of the Camp Director or his/her designate, to advise the primary contact or alternate contact person as soon as possible thereafter.

Furthermore, I/we authorize Camp Freedom to give medications as outlined in the medical forms and assistance with the camper's personal equipment or appliances as necessary in the course of his/her medical treatment and continued well-being while at camp.

AGREEMENT

By clicking either 'Agree' or 'I do not agree', you either grant permission or deny permission for camp staff to administer medicine, medical and/or hospital care as deemed necessary by the medical authority of Camp Freedom. Checking this box confirms that you have read the medical waiver, that you understand it, and that you agree to be bound by it.
Medical Waiver Release Form*

I agreeI do not agree
Today's Date*

MonthDayYear
Signature*

Clear

Early Registration Fees are $395 for applications received on or before April 30th. Regular camp fees are $495. Your invoice will be emailed to you with your confirmation letter.

I will make payment by credit cardI will make payment by E-transferI am in financial need and will apply for the SBHANA Support FundI would like to make a tax-deductable donation to help other campers attend Camp FreedomMy company would be interested in knowing more about Corporate Sponsorship opportunities for Camp Freedom
Should be Empty:

	Completely Independent	Minimal Support	Moderate Support	Full Support
Eating/drinking
Dressing
Showering
Transfers
Catherization
Bowel routine

Teen Camp Freedom Registration Form

Camper Information

Emergency Contact Information

Independence

Medical Information: Allergies

Medical Information: Neurologic

Medical Information: Bladder

Medical Information: Bowel

Medical Information: Executive Functioning and Mental Health

Medical Information: Orthopedic

Medical Information: Skin

Medical Information: Pain Control

Medical Information: Medications

Medical Information: Gynecological

Medical Information: Other

Waivers

Photo, Film, and Video Consent

Medication Waiver