ALL MEDICATIONS BROUGHT TO CAMP MUST BE IN THEIR ORIGINAL CONTAINERS AND LABELED WITH CAMPERS NAME
I give my consent for this child to be surveyed prior to camp programming and again at the completion of camp. I understand that the information collected from the surveys will be used for program evaluation purposes and that youth completion of the survey is voluntary. I understand that any evaluation data collected from the youth surveys will be de-identified, and no personally identifiable information about the youth will be reported.
I give my consent for any non-identifiable information I provide in this application may be used for program evaluation purposes. I understand that any evaluation data collected from this application will be de-identified, and no personally identifiable information contained in this application will be reported.
CAMP TO BELONG MAINEMANDATORY AUTHORIZATION FORM FOR CAMPERS
I hereby give permission for this camper to attend Camp To Belong Summer Camp (CTB) during the period from August 20-25th, 2018. Camp To Belong Maine will take place at New England Golf and Tennis in Belgrade Maine.
Please carefully read each of the following statements:
I understand this child will join his or her sibling(s) along with approximately 80 brothers and sisters placed in separate foster homes or other out-of-home care 8 years of age and above for the duration of the program. CTB will be directed by staff, counselors and volunteers who will be working under the direction of CTB at New England Golf and Tennis.
I understand the mission of CTB revolves around the importance of maintaining and preserving the life-long sibling connection.
I understand the registration and acceptance of this child at CTB is in conjunction with recommendations from the caseworkers, private agency social workers, foster parents, adoptive parents, kinship providers, biological parents, therapists and/or any other child support team member(s). The child’s entire support team understands their role is to prepare this child for camp in a manner that focuses discussion on the opportunity to spend quality time with the child’s siblings and others who share the same sibling separation as well as to garner all clothing and supplies requested for attendance.
I give permission for this child to participate in all camp activities including, but not limited to, outdoor events such as water-skiing, swimming, hiking, wall-climbing, canoeing, along with arts and crafts, themed events, inspirational forums, sibling enhancement and life seminars, unless such activities are specifically discussed as inadvisable between the CTB Camp Director and a member of the child’s support team.
I am assured that while at CTB, any activity requiring transportation via a moving vehicle will have a driver (automobile or van) 21 years of age or older and I release that driver from responsibility should there be an accident in which this child is injured, which is not the fault of the driver.
I understand that I, or an emergency contact, will be called in the event of any major illness or injury and a report will accompany the child home and/or to a caseworker concerning any major or minor illness, injury or incident of concern. If this child needs immediate attention and there is not time to contact me or the emergency contact, I authorize any staff, counselors, or volunteers of CTB and/or any medical clinic, hospital or emergency facility to administer all medicines, prescription drugs and other medical remedies required for, or on behalf of, this child while said child is in attendance and participating at any of the functions or facilities of CTB.
I specifically agree to advise the staff, counselors and volunteers of CTB of all prescribed and required medicines, prescription drugs and other medical needs for this child on a medical form provided by CTB and I give my consent and authority for said staff, counselors and volunteers to administer such medications as prescribed by a physician. I further waive any claim on behalf of myself and this child pursuant to this child.
I further warrant that I have the authority to grant this medical authorization on behalf of this child and agree to hold CTB and/or medical clinic, hospital or emergency facility harmless by reason of my executing this medical authorization.
I hereby give permission to the medical personnel selected by the CTB Camp Director to call for medical care to transport this child to a medical clinic, hospital or emergency facility and to order x-rays, routine tests and treatment for this child.
In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the CTB Camp Director to hospitalize, secure proper treatment for and to order injection and/or anesthesia and/or surgery for this child. This form may be photocopied for use out of camp at outside locations as mentioned.
I understand that I will provide, or make provision for, this child’s transportation to the drop-off and pick-up site to attend camp. I will give this information via a form provided by CTB.
I understand CTB assumes no responsibility for this child’s personal property.
I understand that different venues of videotaping, photographing and audio taping will take place at CTB as part of functions specifically for the campers, internal CTB promotion and external media education. These venues include, but are not limited to, one-time use cameras presented to each child for their own use at camp and thus developed by CTB, Polaroid pictures taken at themed events and presented to each child in a photo frame, and 35mm shots for distribution to campers, counselors and the internal CTB scrapbooks. CTB requires each counselor to submit a confidentiality form that requires understanding that stories and pictures may be confidential. I hereby give CTB full permission to record and use, copyright, reproduce, publish, distribute and exhibit this child’s picture, likeness and/or voice by videotape, photograph or audiotape for purposes of recording the activities of CTB to share internally with the campers, staff, counselors, volunteers and other entities interested in CTB and its mission.
I understand that any question I have regarding videotape, photography or audiotape in conjunction with CTB will be answered to my satisfaction.
I understand that neither I, nor this child, will receive any personal compensation for videotape photography or audiotape, but that this child's participation will serve an important purpose in creating memories and contribute to building awareness of sibling connection in this country and around the world.
I will allow videotape, photograph or audiotape for external media education purposes.
I understand that I do not have to permit this child to be videotaped, photographed or audio taped unless I so desire for external use of the organization for media education purposes.
By hitting submit and providing your signature electronically, you agree that you are the parent or legal guardian of the above-named camper, are over the age of 18 and have permission to agree and sign this application.