Camp 2025 Staff 18+

New Jersey Grange Camp

Camper Registration (Staff)
Camper Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
New to Camp*

YesNo
Please Select All that Apply (Staff will be sent additional instructions for registration)

CounselorKitchenLifeguardOther
Home Number*

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
T- Shirt Size (Please choose either youth -OR- adult *AND* correct size)*

YouthAdultSmallMediumLargeXLXXLOther
Cabin Roomies: Please enter three
We will do our best to accommodate requests, we can not guarantee assignments as each cabin only has 4 bunks
Are you driving yourself to camp?*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*

Area CodePhone Number
Alt. Phone Number*

Area CodePhone Number
Medical/Health History
Allergies
Medical Allergies *
Describe Reaction and management of Reaction Enter N/A if none
Food Allergies *
Describe Reaction and management of Reaction Enter N/A if none
Other Allergies *
include hay fever, asthma, animal dander, poison ivy, insect stings or history of allergies in familyDescribe Reaction and management of Reaction Enter N/A if none
Chronic Concerns: Check all that Pertain.*

This participant has no chronic health problems and is capable of full participation in this program.AsthmaAttention Deficit Hyperactivity DisorderBed-wettingCancer/LeukemiaConvulsions/SeizuresDiabetesEpilepsyFrequent cold and Sore ThroatFrequent Ear infectionsHeadachesHeart Defect/DisorderHemophiliaHypertensionMenstrual CrampsMusculoskeletal DisordersOther
Provide information about supportive health care needed for each checked item:
General History
This participant has had the chicken pox.*

YesNo
This participant has had mononucleosis in the past twelve months..*

YesNo
This participant has a history of illness, injury, or surgery, which will affect.*

YesNo
If yes to Above please explain
If this participant receives care or takes medication for emotional, learning and/or psychological concerns, provide background information to help us work effectively with this person:
The camp Health Care Center keeps basic over the counter medications in stock. If you are bringing prescription medications to camp please keep them in original pharmacy containers, appropriately labeled. List the medications that you will be bringing with you. This information is confidential and seen only by the camp director or health care director.
Medications:
Name of Medications and reason for taking
DRUG & MEDICATION POLICY -[CONSENT TO ADMINISTER MEDICATIONS AT CAMP]

Prescription medication shall be administered only after receipt of written authorization from the child’s parent or guardian.

Prescription medication shall be stored in the original prescription container.

Non-prescription medications shall be administered only after receipt of written authorization from the child’s parent, guardian, or in accordance with the camp’s standing orders. [This includes medications such as aspirin, Tylenol, stomach remedies, etc.]

All Non-prescription medication shall be labeled and stored in the original container as provided by doctor or pharmacist.

No prescription medication is to be kept in the campsites except for rescue inhalers or epipens.

All Prescriptions and Non-Prescriptions are to be given to the camp Health Director upon arrival at camp. Any medications that are not picked up at the end of camp will be destroyed three days after departure from camp.

As a parent/legal guardian of the above named youth member who will be attending NEW JERSEY GRANGE CAMP, I have read and understand the above medication policy and hereby authorize the health/medical staff of the camp to administer the identified prescription and/or “over the counter”, non-prescription medications in the campers personal possession on entering camp and as described in the attached Health History/Medication Release Form.
What “Over the Counter” medicines can this child receive if needed? Parents must check all allowed:

TylenolAdvilIbuprofenPepto BismalAlka SeltzerTumsBenadrylRobitussin (plain)Cough drops/throat lozengesNon-Aspirin AcetaminophenSinus/Allergy Relief TabsCalamine LotionAspirinOther
I give permission for full participation in the Grange programs, subject to limitations herein. In case of emergency, I understand that every effort will be made to contact me (if participant is an adult, my spouse or next of kin). In the event I can not be reached, I hereby give my permission to the health director to secure proper treatment, including hospitalization, for my child (or for me, if participant is an adult).
Signature *

Clear
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the New Jersey Grange Camp and its affiliates including Directors, Counselor, and staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Staff Signature*

Clear
Participation Form
I/We recognize the programs require time, energy, and supervision of members and volunteers of the Grange in order to be a success. After having fully considered the possibilities of harm and injury I/We as the parent(s)/legal guardian(s) of my/our child do accept the responsibility for any injury to my/our child as a result of his/her participating in the aforementioned activity which may occur during travel time, participation in an activity, and any other times involved in the activity, including but not limited to transportation to and from such activities.

I/WE certify that my/our child is in good health, free from physical disability, which would make my/our child’s participation in this activity inadvisable. I/We will advise the moderator of any information that I/we may acquire in the future which would render my/our child incapable for health or other reasons from full participation in this activity. By this participation form, I/we hereby expressly authorize the person in charge of the activity or their designee to permit emergency medical treatment if it becomes necessary and I/we accept personal responsibility for the results and costs of such treatment.

This permission, release, hold harmless, and indemnification is given so that the Grange will allow my/our child to become a participant in the aforementioned activities.

I/We hereby release, hold harmless and will indemnify the New Jersey State Grange, its officers, directors, volunteers, and moderators from all responsibility for claims of personal injury to my/our child which may occur as a result of participating in the Grange activities program.
Staff Signature *

Clear
WAIVER INFORMATION/RIGHT TO OBJECT

The New Jersey Grange may produce or participate in videotape, audio recording, Internet (i.e., Website) or still photograph productions that may involve the use of campers' names, likenesses, or voices. Such productions may be used for marketing purposes and may be copied or copyrighted with the organization retaining any and all rights to such productions.

You have the right to object to the use of your child's name, picture, or voice in these productions and may do so by completing the form below. If permission is not granted for any of the below activites the camper will not partake in group photos
Permission NOT Granted for:

VideotapingAudio RecordingCamp PicturesInternetTelevisionCamp Promotional LiteratureNewspaper Articles/PicturesOther
Camp Code of Conduct

The NJ Grange Camp Code of Conduct is to ensure the safety and well being of all campers and volunteers during the camp week. This code of conduct applies to everyone (campers, volunteers, parents/guardians).

Will:
·       Participate fully in camp activities as defined by the camp schedule. Counselors are responsible for making sure the campers are participating fully unless otherwise excused by the camp director or medical personnel.
·       Dress appropriately for outdoor recreation activities (i.e. cope course, rifle range, archery, field game, waterfront, etc.)
·       Follow their assigned campsite at curfew and are to comply with bunk house rest, lights out, and wake up times.
·       Have a buddy AT ALL TIMES.
·       Cooperate with adult staff and head counselors.
·       Follow all safety policies and procedures.

Will not:
·       Leave the camp premises without staff and director permission.
·       Disobey camp staff/camp policies, rules and regulations.
·       Be disrespectful or use direct profanity, vulgar language, or obscene gestures towards anyone; fighting is not tolerated.
·       Bullying /sexual harassment/derogatory statements/verbal harassment/hazing are 0 tolerance policies at grange camp and any occurrence reported will result in immediate dismissal from the campground with possible indefinite suspension.
·       Sell, give, possess or be under the influence of any illegal drugs or alcohol. Proof of these will result in immediate dismissal from camp with possible alert to local authorities.
·       Violate local, state, federal laws.
·       There is NO smoking on the campground by anyone.
·       Campers under the age of 21 are not permitted to use matches or lighters.
·       Intentionally damage camp facilities; you will be responsible for damages.
·       Tamper with fire extinguishers/ emergency equipment unless there is an emergency.
·       Bring knives, firearms, ammunition, or archery equipment.
·       Bring electronics to camp (including but not limited to: cell phones, cd players, iPods, iPads, video games, kindles, etc.) We are NOT responsible for lost/stolen/damaged items.
·       Wear open toed shoes, bike, or run through camp.
·       Have males in female campsites; have females in male campsites.

Failure to comply with these rules may result in suspension from an activity, removal from the campground, suspension indefinitely from camp. Any violations in local, state, or federal laws will be reported to the local authorities. All forms must be signed by camper and parent/legal guardian, fraudulent paperwork will result in immediate dismissal from the campground.
Staff Signature

Clear
Confirmation

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.
Staff Signature

Clear
Payment*

Check/Money Order
Payable to:

New Jersey State Grange

Send Payment to:

New Jersey Grange Camp C/O Kyle Santos
1234 Chew Rd Waterford NJ, 08089

Registration and Payment due: July 21st

Any issues, questions, or concerns contact camp director prior to date.

Refund & Discount Policy: Available only at NJGCAMP.com Registration Page

The final camp schedule will be posted to the website two weeks prior to camp. We are requesting your eMail Address to alert you of any changes prior to camp and/or if any documentaion is missing.

New Jersey Grange Camp