PART 1: GUARDIAN INFORMATION
PART 2: CAMPER INFORMATION
A. PERSONAL INFORMATION
B. HEALTH INFORMTION
** IF REGISTERING MORE THAN 3 CAMPERS A SECOND APPLICATION WILL NEED TO BE SUBMITTED**
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF NEW JERSEY THAT TO THE BEST OF MY KNOWLEDGE, INFORMTATION AND BELIEF MY CHILD IS IN GOOD PHYSICAL HEALTH AND IS CAPABLE OF PARTICIPATING IN CAMP ACTIVITES, INCLUDING SWIMMING, FEILD TRIPS AND OTHER VIGOROUS PHYSICAL ACTIVITY. I HEARBY AUTHORIZE MY CHILD TO PARTICIPATE IN SUCH ACTIVITES.
Illness, Accident, or LEaving Camp: in the event of serious illness or injury I authorize emergency medical care for my child. I wish my child to be taken to the nearest Emergency Medical Facilty, and the doctor listed below to be modified.
The Senior Staff in the Camp (and their designees) are authorized to dispense perscription medication to students or campers only if the procedures set forth in this policy are followed and the accompanying Meidication Release form is completed in full and filled with the Camp Director.
The parent or guardian of the child must provide the appropriate Senior Staff member with a protocol (substantially in the form o the Prescriber Authorization section on the Medical Release) signed by the physician who prescribed the medication on that (1) describes the dosage to be dispensed; (2) the number of times during the day the medication should be dispensed to the child; and (3) the times of day the medication should be dispensed. If the medication must be given at precise times or interavals, the protocol should state.
The parent or guardian must also provide the appropriate Senior Staff with a written request (as set forth in the accompanying Meication Release) authorizing the staff to store and hand the medication to the child and acknowledging that tje child is responsible for self-administering the medication and familiar with the manner and mode for doing so. The authorization request must also provide contact phone numbers if we must contact the parent or guardian in an emergency of if the child refuses to take the medication.
All medications must be provided to Camp in the original container and must be clearly labeled with the child's name and the original prescript on attached. Without the foregoing information. Camp staff cannot take responsiblilty for dispensing any medication to students. Camp will store all medications in a safe and secure location and will dispense the medications in a Camp office, rather thatnin a classroom. MEdications for Camp campers will be helf by the Program Directors so that they can be dispensed during field trips and in accordance with the information provided on the MEdication Release form. Camp will disoense the medication in compliance with the instructions provided. CAMP WILL NOT ADMINISTER THE MEDICATIONS TO THE CHILD, EVEN IF REQUESTED TO DO SO BY A PARENT OR GUARDIAN.
If the child is uncooperative, Camp will inform the parents immediately. However, Camp reserves the right to refuse to dispenseor to continue to dispense medication to any child if the child is repeatedly uncooperative, if Camp is unable to contact the child's parent or guardian or if compliance with the process otherwise becomes disruptive or ovely burdensome to Camp.
Camp staff will maintain a seperate file for each child to whom medications are being dispensed, which file will be stored in a safe and secure location. Access to file will be limited to Senior Staff (or their designees) responsible for despensing the medication and the Executive Director. The file shall contain ther written protocol and parent authorization form. In addition, Senior Staff responsible for despensing the medication will keep and maintain the file, a contemporaneous record indicating each dosage of medication dispensed and the date and time the medication was dispensed.
If you have any questions feel free to contact us.
Terms and Conditions
The Undersigned participant in Family Camp and his or her parent(s)/legal guardian(s) hereby agree as follows:
My parent(s)/legal guardian(s) and I hereby agree that we will adhere to all of the rules and regulations of Family Camp including without limitations, the medical procedures established by the Family Camp.
My parent(s)/legal guardian(s) and I hereby understand that we must have family medical coverage for me; and that Family Camp will provide full medical coverage at camp for any injuries or illness that may arise during the weeks of the program and are not a result of any preexisting condition. My parent(s)/legal guardian(s) and I further agree that we will bear the cost of my transportation from camp in the the event of illness or if the camp instructor determines, in their sole discretion, that my behavior has violated Family Camp Conditions and Regulations to which my parent(s)/legal guardian(s) and I agree, or that I have acted in a manner detrimental to the safety of, or the successful completion of, the Program. My parent(s)/legal guardian(s) and I also agree that we will accept responsibility for me upon my arrival from Family Camp, and will pay for any property or other damages that the Family Camp Instructor have determined were caused by me. In addition, my parent(s)/legal guardian(s) and I agree that if I must return to my place of departure before the completion of the trip, for any of the above reasons, or for any other reason as determined by the Family Camp Instructor, we will be responsible for the travel expenses to and from my place of origin for an accompanying staff member or medical staff, as deemed necessary by Family Camp instructor.
My parent(s)/legal guardian(s) and I hereby unconditionally release the sponsoring Family Camp, and any of their officers, directors, executives, employees, agents, volunteers and anyone working under, through or in connection with any of them with respect to any incident, claim, occurrence, loss, injury, or damage that could or may arise out of such participation, including, by way of illustration and not limitation, travel to, from, and within the country; home hospitality; use of any and all facilities used for Family Camp or any part thereof; social; cultural and other events (including, by way of illustration and not limitation, trips and educational programs); and any other events or activities in which I may participate or engage, whether or not the same may be deemed to be a part of Family Camp or not, from the time when I shall leave my permanent residence until the time when I shall have returned thereto.
My parent(s)/legal guardian(s) and I hereby acknowledge that we are executing this instrument with full knowledge of the purpose and effect of the contents hereof, that we have had the benefit of legal advice and counsel of our own choosing, and that we execute the same freely and voluntarily, and on the basis that this instrument cannot be altered or revoked except in a writing approved and signed by me, my parent(s)/legal guardian(s), and an authorized staff member of the Family Camp.
By signing below, my parent(s)/legal guardian(s), and I agree to the terms outlined above.