Trooper Island Camper Application

Kentucky State Police Trooper Island, Inc.

Camper Application
Name*

First Name/Middle InitialLast Name
Preferred Name
MaleFemale
Address:*

Street Address Line 2

(City)(State) (Zip)

Postal / Zip Code
Email Address:*
example@example.com
Date of Birth:*

MonthDayYear
Date
Age:*
School Attended:*
Grade camper will be in when school starts:*
Parent/Guardian First, Middle and Last Name: *
Mobile/Home*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone or Alternate:*
Please enter a valid phone number.Format: (000) 000-0000.
Relative or Neighbor Contact

My child can be released to this person if I am not available
Relative or Neighbor First, Middle and Last Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile or Home Phone:*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Yes:No
If yes, when:
Where:
YesNo
SwimmingRunningOther
I AGREE TO OBEY ALL RULES AND REGULATIONS ON THE CAMP AND WILL COOPERATE WITH THE DIRECTIVES OF THE CAMP DIRECTOR, COUNSELORS AND STAFF.
Camper Signature*

Clear
Date

MonthDayYear
Date
I GIVE THE KENTUCKY STATE POLICE AND TROOPER ISLAND , INC. PERMISSION TO ACCEPT MY CHILD AS A CAMPER AT TROOPER ISLAND AND FURTHER RELEASE THE KENTUCKY STATE POLICE AND TROOPER ISLAND, INC., THEIR EMPLOYEES AND VOLUNTEERS OF ANY AND ALL LIABILITY.
Signature of parent / guardian*

Clear
Date

MonthDayYear
Date
KENTUCKY STATE POLICE TROOPER ISLAND, INC. AUTHORIZATION
TO USE PHOTOGRAPHS AND AUDIO VISUAL RECORDINGS
I, (parent/guardian)
parent of
who has been selected to attend a camping session at Trooper Island Inc., do hereby grant permission to Trooper Island Inc., its officers, agents, employees, and other officials or designees, the right to use photographs and audio or visual recordings of my child taken or produced while my child attending or in the application process for attendance at Trooper Island.

I further authorize the use of the photographs and audio or visual recordings, or reproductions thereof, to be used in written, video, website, or other medium used to promote Trooper Island, Inc. and its programs. This authorization includes both use in domestic and foreign markets or exchanges.

In my own behalf, and in behalf of my child, I relinquish and give to Trooper Island, Inc., all right, title, and interest that my child or I may have any photograph, audio, or visual recording, or reproduction thereof, and further grant Trooper Island, Inc., the right to give, sell, transfer, and exhibit any photograph, audio or visual recording or reproduction thereof, to any responsible individual, business firm or publication, or to any of their assignees.

I clearly understand that neither I, nor my child, will receive any compensation for the above grant authorization.
Signature of Parent/Guardian:*

Clear
Date:

MonthDayYear
Date
AUTHORIZATION FOR CAMP ATTENDANCE PHOTO CARD
YesNo
Card will be given to child for them to bring home.
Signature of parent / guardian*

Clear
Date

MonthDayYear
Date
Income Eligibility

For the Summer Food Service Program
PART 1. Full name of child enrolled in camp or closed enrolled sites:*
SNAP, TANF or FDPIR case number (if any)
YesNo
If YES, indicate court ordered case number and attach proper documentation:
Total Household Gross Income
Please tell us how much and how often:

Examples:
$100/monthly
$100/twice a month
$100/Every other week
$100/Weekly

Rows	Name Everyone In Household - Including Children	Earnings from work before deductions	Welfare, Child Support, Alimony	Social Security, Pensions, Retirement	Check if NO income
1
2
3
4
5
6
7
8

Signature*

Clear
Signature and Social Security Number (Adult must Sign)
An adult household member must sign this form. If Part 3 is completed, the adult signing the form must also list the last four digits of his or her Social Security Number or mark the “I do not have a Social Security Number” box.
(See Privacy Act Statement)

I certify that all information on this form is true and that all income is reported. I understand that this information is being given for the receipt of Federal funds. I understand that SFSP officials may verify the information. I understand that if I purposely give false information, the participant receiving meals may lose the meal benefits, and I may be prosecuted.
Date:*

MonthDayYear
Date
Address:*
Phone*
Format: (000) 000-0000.
Last four digits of Social Security Number*
I do not have a Social Security Number
AsianWhiteBlack or African AmericanAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific Islander
Hispanic or LatinoNot Hispanic or Latino
Letter To Households

National School Lunch Program/School Breakfast Program
Dear Parent/Guardian:

Trooper Island Camp takes part in the Summer Food Service Program, a U.S. Department of Agriculture program operated in Kentucky by the Kentucky Department of Education. This sponsor receives federal dollars to help pay for food served to all enrolled children. The amount is based on rates set by the federal government.

*If you now get Food Stamps or Kentucky Transitional Assistance (K-TAP) for your child, your child can get free lunch/breakfast.
*If your total household income is at or below the amounts on the Income Chart, your child may get free or reduced price lunch/breakfast.
*If you have a foster child, that child may be eligible for benefits regardless of your income.

To get free/reduced price meals for your child, carefully complete the application and return it to the school. If you now get food stamps or K-TAP for your child, the application must have the child’s name, your food stamp or K-TAP case number and the signature of an adult household member. If you do not list a food stamp or K-TAP case number, the application must have the names of everyone in the household, the amount of monthly income each household member now gets, where it comes from, the Social Security number of the household member who signs the application or the word “none” if the member does not have a Social Security number. An application that is not complete cannot be approved.
*VERIFICATION: Your eligibility may be checked by school officials at any time during the school year. You may be asked to send information to prove that your child should get free or reduced price meals. *FAIR HEARING: If you do not agree with the school’s decision on your application or the results of verification, you may wish to discuss it with the school. You also have the right to a fair hearing. You can do this by calling or writing the following official:
PARENT NAME*
PHONE*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OTHER INFORMATION:
Wages/salaries/tips Strike benefits Unemployment compensation Workers’ compensation Net income from self-owned Business or Farm

Public assistance payments Welfare payments Alimony payments Child support payments

Pensions Retirement income Social Security Veteran payments Supplemental security income

Earnings from second job Disability benefits Interest/dividends Cash withdraw from savings Income from estates/trusts/investments Regular contributions from person not Living in the household Royalties/annuities/rental income Any other monies that may be available to Pay for child’s meals.
PRIVACY ACT STATEMENT

The Richard B. Russell National School Lunch Act requires the information on this application. You do not have to give the information, but if you do not, we cannot approve your child for free or reduced price meals. You must include the social security number of the adult household member who signs the application. The social security number is not required when you apply on behalf of a foster child or you list a Food Stamp, Temporary Assistance for Needy Families (TANF) Program or Food Distribution Program on Indian Reservations (FDPIR) case number for your child or other (FDPIR) identifier or when you indicate that the adult household member signing the application does not have a social security number. We will use your information to determine if your child is eligible for free or reduced price meals, and for administration and enforcement of the Program.
Trooper Island Camp takes part in the Summer Food Service Program, a U.S. Department of Agriculture program operated in Kentucky by the Kentucky Department of Education. This sponsor receives federal dollar to help pay for food served to all enrolled children. The amount is based on rates set by the federal government. Thank you for filling out an application and helping the sponsor provide nutritious meals and snacks that can help your child grow stronger and healthier. If you any questions about the Summer Food Service Program application, please give me a call at 270-433-5422.

Sincerely,
Tpr. Scott Ferrell
Camp Director/Commander Trooper Island Camp
Non-discrimination Statement

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. To file a complaint of discrimination, write to USDA, Director, Office of Adjudication, 1400 Independence Avenue, SW, Washington DC 20250-9410 or call (866) 632-9992 (Voice) Individuals who are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339: or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and employer.
Camper Medical History and Release

(To be completed by Parent/Guardian)
Camper Social Security Number:*
YesNo
If yes, indicate Carrier or Plan Name and Group #:
Recent injury or illnessFrequent headachesWear glasses or contactsHigh Blood PressureDiabetesEver had surgeryEver been hospitalizedNose bleedsSinus troubleSpeech impedimentADD/ADHDAnxietySleep WalkingEver had a head injuryFrequent ear infectionsHeart murmurAsthmaMenstrual CycleEating disorderHeart ConditionConvulsionsDeaf or hard of hearingODDBedwettingBeen knocked unconsciousSeizuresSkin problemsHad mononucleosis in last 12 monthsDepressionUlcerFainting spellsOCDHead Lice, if yes list when
Explain any conditions not listed:
YesNo
Please List All Known Allergies:

If none, please indicate NONE in the fields below
Medication Allergies*
Food Allergies Other Allergies*
Other Allergies*
Emergency Contact other than Parent or Guardian*
Phone Number*
Format: (000) 000-0000.
Date*

MonthDayYear
Date
Parents/Guardian: When we assume the responsibility of your child, we put his/her safety and health above all other considerations. Doctors are not permitted, by law to perform surgery and administer many other treatments to a child without the parent’s consent. If the need arises, every effort will be made to allow you to make such decisions, but if circumstances make it necessary, you would want us to be free to act on behalf of your child, according to the best advice available. To make this possible, we ask that you sign the following statement and return it with the application.

I HEREBY AUTHORIZE THAT PERSONS AND AGENCIES ENTRUSTED WITH THE CARE OF MY CHILD WHILE ENROUTE TO AND FROM AND WHILE AT TROOPER ISLAND CAMP, WHICH IS OPERATED BY THE KENTUCKY STATE POLICE, TROOPER ISLAND, INC., TO FOLLOW THE ADVISE OF THE BEST AVAILABLE MEDICAL AUTHORTIES AND ADMISISTER ANY TREATMENT, INOCULATIONS, MEDICINES AND SURGICAL PROCEEDURES DEEMED NECESSARY TO MY CHILD’S SAFETY. I ALSO AUTHORIZE THE TROOPER ISLAND CAMP STAFF TO ADMINISTER ANY MEDICATIONS, AS DEEMED NECESSARY.
Signature of parent/guardian

Clear
Trooper Island Camper Medication Schedule
Camper’s Name*
INSTRUCTIONS: The following must be completed for each prescription that is to be taken by your child during camp. Please list medication in the order in which they are to be taken. This includes inhalers. ALL MEDICATION SHALL BE IN THEIR ORIGINAL PRESCRIPTION BOTTLES. ANY MEDICATION NOT IN THEIR ORIGINAL BOTTLE SHALL NOT BE ADMINISTERED.
List of Medications: 1
2
3
4
5
6

BREAKFAST:

Rows	Medication Name	Dosage	Special Instructions
1
2
3
4
5
6

LUNCH:

Rows	Medication Name	Dosage	Special Instructions
2
3
4
5
6

DINNER:

Rows	Medication Name	Dosage	Special Instructions
1
2
3
4
5
6

BEDTIME:

Rows	Medication Name	Dosage	Special Instructions
1
2
3
4
5
6

Other medication notes:
Camp Information

The camper will be transported to and from camp on the Trooper Island Bus. The return trip from Trooper Island will depend on weather conditions. Departure time is scheduled between 12:00 p.m. and 1:00 p.m. C.D.T.

Medication: Please pack any type of medication (prescription or non-prescription), in its proper container. If you identify your child as having a condition such as ADD/ADHD or similar condition, make sure that the proper medication is sent with your child. Campers are not allowed to keep medication on their person.

Things to bring:
- Minimum of five (5) changes of clothing, which should include shorts and shirts and at least one (1) pair of long trousers.
- Male: Swim trunks or shorts – Female: Swimsuit should be One Piece or a Tankini.
- Necessary underclothes
- Jacket
- Towels, washcloths, toothbrush, toothpaste, comb / brush, shampoo, deodorant and soap.
- Cap or visor
- Tennis shoes (old/comfortable)
- Socks, and Flip Flops or Shower Shoes.
- May bring a flashlight, but not required
- Small amount of money (no more than $5.00). This is to be used in case the bus stops whileenroute to or from the island.
Do NOT Bring:
- Sleeping Bag or any other type of bedding
- Excess luggage
- No type of knife, firearms, fireworks, lighters, electronic device or component, jewelry,makeup, tobacco products, etc.
- No food / drinks or snacks
- Do Not send cell phones with camper
- Any item found will be confiscated by camp director or designated KSP employee
- Trooper Island is not responsible for any of these items if lost or damaged.
Camp Activites List
While reading the activities below, be thinking about how you would rate these classes 1-8. This will help staff put each camper in classes they will enjoy. (Campers will have the opportunity to choose their classes upon arrival

Archery- The purpose of the course is to introduce campers to the basic techneiques of the outdoor t get archery, emphasizing the care and use of equipment, range safety, stance, and shooting techniques, scoring and competition.

Swimming- (Upon arrival, all children will be required to take a swim test. Based on the lifeguards judgement, children will be placed into beginning swimming if the y see fit

Beginning Sw imming- The goal is to get campers comfortable and able to enjoy the water safely. They will learn basic water skills such as floating, blowing bubbles, leg and arm movemenrts, as well as exploring the water.

Advanced Swimming- Advanced swimming focuses on teaching campers higher level strokes such as: breast stroke, butterfly, freestyle, etc. This class also off ers multiple water games giving campers the chance to experience team building skills.

Kayaking- This class introduces the basics of kayaking. It will teach campers how to properly paddle, balance skills, water safety, self awareness, and allows them to have a chance to experience the lake.

Fishing- This class offers the basic technuqies of when, where, and how to fish. Campers will learn all parts of a fishing pole, how to bai t and cast a line, as well as remove a fish from a hook.

American Sign Language- This class will teach ASL mannerisms, ASL alphabet, and small phrases to communicate with those who know ASL or are impared through speech or hearing.

Nature- This class will guide campers to learn various orginisms and plants of the outdoors. Campers will learn proper ways to build and put out fires, learn animal tracks, as well as survival skills.

Range- This class will educate children on gun safety as well as the proper mechinisms in shooting guns. Campers will be able to shoot a .22 riffle and compete in a competition for Top Shot!

Recreation- This class will give campers the opportunity to ply organized games, and build teamwork skills. Campers can expect to play more than just your basic sports including games such as furniture, blind samurai, freeze tag, and more!

Trooper Island Application - Revised 1/14/26
Should be Empty:

Kentucky State Police Trooper Island, Inc.

Relative or Neighbor Contact

AUTHORIZATION FOR CAMP ATTENDANCE PHOTO CARD

Income Eligibility

Letter To Households

OTHER INFORMATION:

PRIVACY ACT STATEMENT

Non-discrimination Statement

Please List All Known Allergies:

Trooper Island Camper Medication Schedule

Camp Activites List