Bleeding Disorders of Kentucky Camp Fusion Application

Bleeding Disorders of Kentucky Camp Fusion Application

June 16, 2024 - June 20, 2024
What happens during a week at Bleeding Disorders camp?
- Fun, Fun and more Fun!!
- So Many Activities (saltwater swimming pool, fishing, kayaking, archery, challenge course, miniture golf, campfires, and much more).
- We are a technology free camp so please leave cell phones and other devices at home.
- Camp Fusion 2024 is in a new location and we think you are going to love it! Check out https://camphorsinaround.org/ for more details on the camp location.
Who is eligible?

Any child (6-15yrs) with a bleeding disorder diagnosis

How will my camper’s medical care be provided?

HTC medical personnel will always be available on site.

What else do I need to know?
- If medical equipment is brought for your camper, please bring a surge protector that is clearly labeled with the child’s name on it.
- If your child has a service dog at home, we would ask that you keep the dog at home during the week. We have staff who can assist your child with any needs while at camp.
- Camp Admissions will communicate with you by e-mail. Please make sure your e-mail address is written clearly on your application. If no e-mail address is provided, documents will be mailed to you by U.S. Mail.
- Once your child’s application is submitted, you will be provided with additional health guidance documentation.
Application Deadline: 06/07/2024
- Click Submit to submit your Camper Application
- Upload requested insurance and vaccination documentation to the application
- If unable to upload requested documentation, fax to: 502-210-4232

REQUIRED IMMUNIZATION INFORMATION:
l attest that my camper attends a public or private school that requires full immunizations.I attest that my camper is exempt from immunizations for medical reasons.
Explain (You will be required to submit a medical exemption form we will provide. We may or may not be able to accept children based on immunization status and the need to protect the larger community)
Date of last tetanus booster:

MonthDayYear
Date
OR
Upload a copy of your camper's most recent vaccination record:

Cancelof
**In order to minimize the risk of COVID transmission, campers will be participating in mandatory COVID precautions. These may include, but aren't limited to prescreening, testing, masking, hand sanitation, and temperature checks.**
My camper has been fully vaccinated against COVID-19 (two weeks following your 2nd vaccine dose)?*

YesNo

**Please complete medication list including dosage, time medications are administered, how medication is administered, and purpose of medication. Following submission of application, BDoKY will provide this form to your camper's bleeding disorder physician for review and signature. Camp Fusion's medical director will contact you, prior to camp, with any qustions or needs regarding your camper's medical care.**

Please list all medications, including over the counter (OTC):

	Medication Name	Dosage	Times medication is given	How medication is given	Purpose of Medication
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10

Child must bring all medications in the original container.
Physician’s Statement:

I have reviewed the records and acknowledge that the camper, (name below) is physically able to attend camp.
Camper's Name:

First NameLast Name
What is the child's bleeding disorder diagnosis?
Physician/Nurse Practitioner/PA's Signature:

Clear
Date

MonthDayYear
Date
Physician/Nurse Practitioner/PA's Name (PRINT)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid phone number.
Emergency Number:
Please enter a valid phone number.

Parental Waiver and Consent Form

Authorization and Acknowledgment: By signing this waiver and consent, I, the legal parent/guardian grant permission for myself/my children to participate in any and all activities including but not limited to lifeguard supervised swimming, lifeguard supervised boating and fishing, horseback riding, and the rock climbing wall under supervision of certified instructors unless otherwise specified on the Camper Application Form. I recognize and acknowledge the inherent risks that these activities may present for my children.

I acknowledge that the possession or use of alcoholic beverages and illegal drugs are strictly forbidden. I understand the possession of any weapon (firearm, knife, explosives, etc is strictly forbidden on camp property.

I authorize Bleeding Disorders of KY (BDOKY) to release my demographic information to supporting affiliates who help with the cost of my child attending camp. Because I acknowledge the risks of allowing my children to participate, I agree to release and hold harmless BDOKY, the facility, its founder, trustees, directors, officers, employees, agents, affiliates, volunteers and medical staff (“Staff”) from any and all injury claims of any other nature which may result from my children’s participation at and travel to or from camp. I agree to indemnify and hold the staff and other children at camp harmless from any and all liability caused by my children, whether or not intentional.
Medical Consent: The camp will make every effort to contact me in the case of an emergency. I give my permission for BDOKY and its medical staff to administer any medications needed and to provide and arrange for any necessary medical treatment to my children while at camp, including onsite and offsite emergency care. I accept responsibility for the costs of all such medical treatment.*

I accept medical care for my childI decline medical care for my child
Photography Release: In consideration of my children’s participation at camp, and without any further consideration from BDOKY, I hereby grant permission to the BDOKY, camp, staff and affiliates to utilize my appearance, performance or voice in any and all manner and media throughout the world for the purpose of promotion, reporting or publication. BDOKY may use my children’s photograph, likeness, voice and biographical material in connection with publication, promotion, exhibition and distribution of such material. I understand that no royalty, fee or any other compensation of any kind shall become payable to me by reason of such release and use of any photograph.*

I accept photography release for my childI decline photography release for my child
Camper's Name:*

First NameLast Name
Parent/Guardian must sign. Signature represents legal authority for child listed above.
Parent/Guardian Name:*

First NameLast Name
Parent/Guardian Signature:*

Clear
Date:*

MonthDayYear
Date
THIS CONSENT FORM IS VALID FOR ONE YEAR FROM DATE OF SIGNATURE.
Should be Empty:

Bleeding Disorders of Kentucky Camp Fusion Application

KY Bleeding Disorder Camper Medical Form

Function Rating Scale

Additional Medical Information