A PARENT AND AN ADDITIONAL PERSON MUST BE AVAILIBLE FOR CONTACT 24 HOURS/DAY

If a second parent or legal guardian is not available, please list an alternate emergency contact, including name and phone number.

Bleeding Disorder Information
Instructions: Please send enough Factor concentrate for scheduled prophylaxis and extra emergency bleed doses. Campers who treat on-demand with factor MUST send emergency doses along with any other medicines that are a part of the treatment plan. Check expiration dates before sending meds to camp.

Instructions: Provide detailed information/Medication needs etc. to any boxes checked YES in the "Additional Information" box. If the condition requires medication, please list in MEDICATION SECTION. An HTC nurse may contact you before camp to discuss your camper's medical needs.

Please make sure a copy of your child's immunization record gets uploaded with their PCP Medical Clearance Form (See below under Health Examination). Immunization documentation MUST be received prior to July 1st, 2026.

Please list all medications that will be taken during camp, include factor and any over-the-counter drugs. All medications, vitamins and dietary supplements will be kept in the Health Hut and records of use during camp will be maintained.

All medications must be labeled with THE CAMPER'S name

• Parent consent must be in writing (below).
• Prescription medication must be in its original container with a clear and accurate pharmacy label, which can be accepted as physician instructions. "Take as directed" or "as needed" is NOT specific and cannot be accepted as direction. You can request a duplicate medicine label from your pharmacy.
• If the directions on the bottle are different from what the physician is currently prescribing, written instruction is required from the physician.
• All medications (especially asthma inhalers/medications, Flonase, or Epipen) requiring a prescription from a doctor needs to be sent to camp with your camper.
• ALL medications must be un-expired. We cannot accept expired medications.
• If your child has a bleeding disorder, remember to bring an adequate supply of factor for prophylaxis and to treat any bleeding episodes. If your child has a mild bleeding disorder, he/she needs to bring one "life-saving" dose of factor to camp. Remember to bring Amicar/Tranexamic acid and Stimate, if responsive.
• Place all medication required at camp in a zip-loc bag labeled with your child's name. Carry the medication bag separately and give it directly to the health hut team. If the medication has been packed away, you will need to find it and give it to the nurse before your child gets on the camp bus or takes his or her bags to the cabin if being dropped off at camp.
• EXCEPTIONS: Children requiring inhalers or insect sting kits may keep those items with them; however, this consent form must be signed and the medication must be shown to the health hut team at the start of camp.
• At the end of camp the health hut team will return any left over medication to you. If you, or another adult assigned by you, does not pick up the medication when you pick up your child, it will be secured at the HTC for you to pick up at a later time.

Campers with a bleeding disorder must have seen their Primary Care Provider (PCP) within the 12 months prior to camp. Download the medical clearance form below, have it completed and signed by your PCP, and upload the form once complete.

We will send you a Release of Information Form upon completion of your application to authorize the BDFW to work with your HTC to obtain the clinic notes from your last HTC appointment.

The Bleeding Disorder Foundation of WA/Camp I-Vy camp adheres to the highest safety standards and regulations. Camp I-Vy Summer Camp seeks to inspire children within the bleeding disorder community to develop independence, explore, leam, make friends, and become their greater selves through a week of outrageously fun activities in a safe and secure resident camp environment.

Disciplinary Process: Most disciplinary situations at camp are minor and can be resolved with minimal corrections. A disciplinary action at camp is never physical. Initially, discipline can be in the form of a verbal reminder of cabin and camp-wide rules, or if necessary, may entail the camper missing all or part of an activity. Camp staff members use discipline as a learning opportunity for the camper and try to integrate problem-solving skills into the discussion. However, if the negative behavior continues the following steps may be instituted:

1. Discussion between camper and counselor with set goals and objectives.
2. Discussion between camper, head counselor, or camp director regarding expectations.
3. If the conduct continues, a documented behavioral contract may be instituted and signed by camper, counselor, and camp director.
4. Camp Director will contact parent/ guardian to inform them of situation and to discuss possible options up to and including shortening the camp stay.
5. Camp Director will contact parent/ guardian to make arrangements for the camper to be escorted home.

Although the above steps may be implemented, camp administrative staff retains the right to take immediate action if the camper's behavior poses a threat to their own safety, the safety of other campers, or the camp staff. There will be no refund of any amount for campers who are sent home because of behavior problems. Tobacco products, alcohol, illegal drugs, weapons, and sexually explicit material and/or behavior are grounds for immediate dismissal from camp.

The following rules and regulations apply to all campers. The rules and regulations apply for the entire week while camp is in session. Please read them carefully and accept them by placing your signature where indicated:

1. Camp is about fun/ exploration/ and growth. Respect for all in this process is the basic expectation.
2. Possession of personal electronic devices including cell phones, electronic tablets, gaming devices, etc is prohibited. If found at the camp, they will be held by the camp director until the end of the camp session.
3. Possession of weapons of any kind including sling shots, knives, pellet guns, and water guns are prohibited. If found at the camp, they will be held by the camp director until the end of the camp session.
4. Respect the animals and plant life on the hosting camp, Camp Huston grounds and wherever camp activities take place.
5. Hike only on designated hiking trails.
6. For the health of all campers, pets of any kind are not allowed on the Camp
   Huston grounds.
7. As Washington Health Department regulation, campers are not allowed to sleep on the cabin floor.
8. Report any broken equipment or damage to camp property to the camp director immediately. Payment for damage to camp property beyond normal wear and tear will be the responsibility of the parties involved.
9. Rooms must be clean and in order at the end of the camp session.
10. Food and beverages are not allowed in the sleeping rooms and pool area.
11. Shirts and shoes or sandals are required to be worn at all meals in the dining
    hall.
12. Immediately report bleeds, cuts, scrapes and other injuries requiring medical
    attention to the staff nurse or doctor.
13. Campers must respect the rights of privacy of others.
14. All campers are to be in their assigned cabins and quiet at lights out.

I, the camper, accept the rules and regulations above and agree to follow them at
all times while at Camp I-Vy/Camp Huston.

At camp, your child will have the opportunity to learn self-infusion/infusion
instruction on a voluntary, informal and individual basis by trained medical staff.
Your child can receive this important training when the camper needs factor
replacement during camp, but only if the child is voluntarily ready to infuse themself
or their sibling. I grant permission for my child to receive infusion instruction.

I grant permission for my child to receive treatment for bleeding disorders, including infusion of factor and/or accessing port, while at camp. I grant permission for my child to receive treatment for any medical problems while at camp.

If your child has a minor health problem that can be treated with over the counter medications, ointments, bandages or splints, the health hut staff, physical therapists or physicians may provide care if you approve. A small supply of over-the-counter medications is available at camp. These medications are dispensed, as needed, under the standing orders of the WACBD camp health hut team. Your personal physician does not need to sign for the medications listed below. The health history form is checked for allergies before any medication is given. List all medications you do NOT approve to be administered to your child if needed. Medications stocked at camp are listed below. Brand names have been listed, but their generic equivalent or the same medication of a different brand name may be substituted. Injectable Epinephrine is a prescription medication that is kept on site for use in the event of a life-threatening allergic reaction.

I authorize the Bleeding Disorders Camp health hut team to dispense over-the-counter medication under the direction of the consulting physician's standing orders, as needed, to my child while at Bleeding Disorders Camp.

Taken by Mouth:

• Non-aspirin pain/fever relievers [acetaminophen/Tylenol], liquid, gel caps and pills
• Decongestants
• Ibuprofen
• Imodium (anti-diarrheal)
• TUMS, Maalox or other antiacid
• Throat lozenges (Cepacol)
  Creams & Ointments:
  - Antibiotic cream or ointment
  - Cream for itching (Hydrocortisone)
  - Sun burn cream or gel (Aloe Vera)
  - Blistex
  - Silvadene (for burns)
  - Athlete's foot cream (Lotrimin)
  - Calamine lotion
  - EMLA or other numbing cream
  - Sunscreen
  Sprays & Others:
  - Afrin/Neo-synephrine
  - Nasal Cease
  - Nasal QR
  - "Bug" spray
  - Throat spray (Chloraseptic)
  - First aid spray (Bactine)
  - Soap for posion oak (Teonu)

I give my permission for my camper to take part in all camp activities. In consideration of the benefits derived from my child's attendance at Camp I-Vy, I expressly waive all claims against the camp and its staff, the Bleeding Disorder Foundation of Wa, it's officers, trustees, agents and employees on account of any accident, injury and/or illness that may occur to my child during camp.

From time to time, the Bleeding Disorder Foundation of WA, will want to use
pictures from camp to promote Camp I-Vy and Bleeding Disorder Foundation of WA
activities. We would like permission to be able to use your child's image for that
purpose. I give my permission to use my child's image in print, video, or electronic
media, including internet and social media.

• Please read this document carefully. It must be signed by all Participants attending
  or participating in programs and activities at Camp Huston, or by at least one parent
  or guardian of all Participants who are under the age of 18 as of the date of
  attendance at the camp.

It is acknowledged that attendance at and participation in camp activities at Camp
Huston exposes participants to certain risks that cannot in all cases be reasonably
anticipated or avoided, including the risk of property damage, illness, bodily injury
and death. In consideration of Participant's attendance at participation in such
activities, and the use of any facility or equipment of Camp Huston, and
engagement in and/or receipt of instruction in any activity or activity incidental there
to, the undersigned hereby (1) expressly assumes all such risks, known and
unknown and inherent or not; and (2) voluntarily and absolutely releases,
discharges, waives and relinquishes any and all claims, liabilities, demands,
damages or actions, of any form or nature, for property damage, bodily injury and
death, arising from or in any way relating to Participant's attendance at and
participation in activities at Camp Huston, including, but not limited to the use of any
facility or equipment of Camp Huston, and engagement in and/or receipt
of instruction in any activity or activity incidental thereto.

The foregoing release, waiver and discharge of claims shall be extended and be
effective as to Camp Huston, Inc., an Washington nonprofit corporation, and theirrespective directors, officers, employees and agents, to the fullest extent permitted by Washington law.

This agreement is entered into voluntarily and after careful consideration of its
terms, and shall be binding upon the Participant and the undersigned
Parent/Guardian, if signed by a Parent/Guardian, and their respective heirs,
successors, personal representatives and assigns.