camp amigo 2018 july 15-21, 2018 natahala outdoor center...
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Camp Amigo 2018July 15-21, 2018
Natahala Outdoor Center, Bryson City North CarolinaChild (Camper) Application
NAME: ___________________________________________ SEX: MALE______ FEMALE_______ AGE: _____
ADDRESS: _______________________________________ DATE OF BIRTH: ____________________________
__________________________________________________ SOCIAL SECURITY #: ________________________
PHONE: ___________________________________________ EMAIL: _____________________________________
MOTHER’S NAME: ________________________________ T SHIRT SIZE (ADULT): S___ M___L___XL___
PHONE: ____________________________________________ XXL____
FATHER’S NAME: __________________________________
PHONE: _____________________________________________
MEDICAL/ INSURANCE INFORMATION
HEALTH INSURANCE COMPANY: ______________________________________________________________
POLICY #:___________________________________________ EXPIRATION: ____________________________
MEDICARE/ MEDICAID #: _____________________________________________________________________
DOCTOR’S NAME: _________________________________________________ PHONE: ___________________
HEALTH CONDITIONS: _________________________________________________________________________
ALLERGIES: ____________________________________________________________________________________
EMERGENCY CONTACT INFORMATION
WE MUST HAVE AT LEAST TWO CONTACTS WITH AS MANY PHONE
NUMBERS AS POSSIBLE.
1. NAME: _______________________________________ RELATIONSHIP TO CHILD: __________________
PHONE # (AS MANY AS POSSIBLE): ___________________________________________________________
_________________________________________________________________________________________________
2. NAME: _______________________________________ RELATIONSHIP TO CHILD: ___________________
PHONE # (AS MANY AS POSSIBLE): _____________________________________________________________
__________________________________________________________________________________________________
BY SIGNING, I AGREE TO ALLOW MY CHILD TO ATTEND CAMP AMIGO FROM JULY
15-21, 2018. I UNDERSTAND THAT INAPPROPRIATE BEHAVIOR BY MY CHILD MAY RESULT IN
HIM/ HER BEING SENT HOME EARLY AT MY EXPENSE.
CAMPER’S SIGNATURE: _________________________________________________ DATE: ______________
PARENT’S SIGNATURE: __________________________________________________ DATE: ______________
CAMP AMIGO 2018MEDICAL INFORMATION
PLEASE FILL OUT COMPLETELY
HOW DID THE CAMPER RECEIVE THEIR INJURIES? ________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
IS THE CAMPER REQUIRED TO WEAR PRESSURE GARMENTS OR SPLINTS? Y___ N ____ If YES, PLEASE PROVIDE DETAILED INSTRUCTIONS FOR CARE____________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
DOES CAMPER HAVE ANY ARTIFICIAL LIMBS? Y____ N ___
IF YES, PLEASE PROVIDE DETAILED INSTRUCTIONS FOR CARE _____________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
PLEASE LIST ANY ALLERGIES (FOOD MEDICATION ETC.) THE CAMPER HAS __________________________________________________________________________________________________
__________________________________________________________________________________________________
IS THERE ANY OTHER MEDICAL INFORMATION WE SHOULD KNOW ABOUT THE CAMPER? __
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
**IF YOUR CHILD REQUIRES MEDICATION, PLEASE SEND ONLY ENOUGH FOR HIS/HER STAY AT CAMP WITH DETAILED INSTRUCTIONS AND IN
THE ORIGINAL CONTAINER**
THE MEDICAL INFORMATION PROVIDED IN THIS APPLICATION WILL ONLY BE AVAILABLE TO CAMP STAFF, IF NEEDED, AND TO MEDICAL PERSONNEL, IN CASE OF AN EMERGENCY.
BY SIGNING THIS FORM, THE PARENT/GUARDIAN IS GIVING THE CAMP DIRECTOR AND CAMP MEDICAL STAFF PERMISSIONS TO PROVIDE MEDICAL TREATMENT TO THE CAMPER (CHILD) IF IT IS NEEDED.
PARENT/GUARDIAN SIGNATURE: ________________________________________ DATE: ______________
Name of Medication and Dosage Times to be Given
****ALL MEDICATIONS MUST BE IN THEIR ORIGINAL CONTAINERS****
QUESTIONNAIRE
DID YOU COME TO CAMP IN 2017? IF YES, WHO WAS YOUR COUNSELOR? _____________________
WOULD YOU LIKE THE SAME COUNSELOR AS YOU HAD LAST YEAR? (THIS DOES NOT GUARANTEE THAT YOU WILL HAVE THE SAME COUNSELOR BUT WE WILL TRY EVERYTHING WE CAN FOR YOU TO HAVE THE SAME ONE) ______________________________
WHEN GOING TO CAMP, WHAT ARE SOME OF THE THINGS THAT YOU WOULD LIKE TO DO? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
ARE THERE ANY SPECIAL FOOD REQUESTS THAT WE NEED TO BE AWARE OF? (VEGAN, VEGETARIAN, ETC) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ _____________________________________________________________________________________________
CAMP AMIGO 2018 July 15-21, 2018
*WAIVER AND RELEASE*
RELEASE TO USE PHOTOS AND/OR FILM
MY CHILD WILL BE ATTENDING CAMP AMIGO FROM JULY 15 THROUGH JULY 21, 2018 AND WILL BE PARTICIPATING IN ACTIVITIES OFFERED. I GIVE MY PERMISSION FOR CHILDREN’S BURN CAMP OF NORTH FLORIDA, INC. TO TAKE PHOTOGRAPHS (DIGITAL OR OTHERWISE) AND VIDEO FOOTAGE OF MY CHILD. I UNDERSTAND THAT PHOTOGRAPHS AND VIDEO THAT INCLUDE MY CHILD MAY BE USED TO PROVIDE THE GENERAL PUBLIC AND OTHERS INFORMATION REGARDING BURN INJURIES AND PREVENTION, AND TO INFORM THEM ABOUT CAMPS LIKE OURS.
LOCAL MEDIA FROM TALLAHASSEE, JACKSONVILLE, AND GAINESVILLE ARE INVITED TO ATTEND THE LAST FULL DAY AT CAMP. THERE IS A POSSIBILITY THAT YOUR CHILD WILL APPEAR ON THE TV NEWS OR IN THE PAPER, HAVING A GREAT TIME AT CAMP!
**A PARENT/GUARDIAN OF EVERY CHILD ATTENDING CAMP MUST SIGN THE RELEASE**
PARENT/GUARDIAN SIGNATURE: _______________________________________DATE: ________________
**THE PHOTOGRAPHS AND VIDEO TAKE AT CAMP WILL ONLY BE USED BY CHILDREN’S BURN CAMP OF NORTH FLORIDA, INC. (CAMP AMIGO) FOR THE PURPOSES STATED ABOVE.
PHOTOS AND VIDEO WILL BE TAKEN DURING ALMOST EVERY ACTIVITY BY CAMP STAFF AND OTHER CAMPERS. WE DO NOT ALLOW OTHER ENTITIES OR PERSONS ON THE
PREMISES, UNLESS SPECIFICALLY APPROVED AND INVITED. **
CAMP AMIGO 2018JULY 15-21, 2018
CAMPERS MINIMUM STANDARDS OF CONDUCT
THESE STANDARDS HAVE BEEN DEVELOPED TO PROTECT CHILDREN’S BURN CAMP FO
NORTH FLORIDA, INC. (CAMP AMIGO) IT’S VOLUNTEER COUNSELORS AND ITS CAMPERS.
ALL CAMPERS MUST READ AND ADHERE TO THE FOLLOWING RULES. ANY CAMPER THAT
VIOLATES THESE RULES OR ANY OTHERS SET FORTH DURING THE COURSE OF CAMP.
MAY BE ASKED TO LEAVE CAMP IMMEDIATELY AND MAY NOT BE INVITED BACK TO CAMP
THE FOLLOWING YEAR.
• NO ALCOHOL OR ILLEGAL SUBSTANCES OF ANY KIND WILL BE PERMITTED.
• NO FIREARMS OR WEAPONS OF ANY KIND. THIS INCLUDES: GUNS, KNIVES,SLINGSHOTS, FIREWORKS, OR ANY OTHER ITEM THAT COULD BEHARMFUL TO THE CAMPER OR OTHERS.
• NO FIGHTING. THIS INCLUDES VERBAL AND PHYSICAL FIGHTING. IFTHERE IS A PROBLEM WITH ANOTHER CAMPER, PLEASE FIND A STAFFMEMBER AND THEY WILL RESOLVE THE PROBLEM.
• NO ENTERING OTHER CAMPERS’ OR COUNSELORS’ LIVING AREA WITHTHEIR PERMISSION.
• NO DISTURBING OTHER PEOPLE’S PROPERTY WITHOUT THEIR CONSENT.
• NO DISPLAYING OR PRESENTING MATERIAL, SONGS, ACTIVITIES, ORMESSAGES THAT DEGRADE, INSULT, OR FRIGHTEN OTHERS, OR THAT ARE
AT THE EXPENSE OF OTHERS. (BE NICE!!!)
• NO INAPPROPRIATE ATTIRE. THIS MEANS NO SUGGESTIVE CLOTHINGINCLUDING BATHING SUITS.
• YOU ARE REQUIRED TO SMILE AND LAUGH OFTEN AND HAVE A GOODTIME!!!
WITH MY PARENTS/GUARDIANS I HAVE COMPLETED THE CAMPER APPLICATION AND HAVE
READ AND UNDERSTAND THE RULES FOR MY CONDUCT AT CAMP. I WILL TAKE
RESPONSIBILITY FOR MY ACTIONS AND CONDUCT MYSELF IN A MANNER THAT ENSURES MY WELL-BEING. I WILL EXERCISEGOOD JUDGEMENT IN ALL MY ACTIONS AND I WILL
FOLLOW THE RULES AND COOPERATE WITH THE CAMP STAFF BECAUSE THEY ARE THERE
FOR MY SAFETY.
MOST IMPORTANTLY, I UNDERSTAND THAT IF I DO NOT FOLLOW THE RULES, I MAY BE
SENT HOME EARLY AND I MAY NOT GET TO COME BACK TO CAMP NEXT YEAR.
CAMPER’S SIGNATURE: _______________________________________________ DATE: _________________
PARENT/GUARDIAN SIGNATURE: ________________________________________ DATE: ______________
WHAT TO EXPECT & WHAT NOT TO EXPECT
WHAT TO EXPECT
TO WALK A LOT
TO SPEND A LOT OF TIME TOGETHER AS CAMPER AND COUNSELOR TO BE ON YOUR BEST BEHAVIOR
TO TRY MANY DIFFERENT THINGS
TO LEARN A LOT ABOUT OTHERS AND YOURSELF TO BE EXHAUSTED
TO BE FRUSTRATED AT TIMES
TO HAVE YOUR SENSITIVITY TESTED TO LAUGH HARDER THAN YOU EVER HAVE BEFORE
TO MISS HOME AND SOMETIMES WONDER IF YOU SHOULD HAVE COME
TO FOLLOW THE RULES TO DO THINGS YOU’VE NEVER DONE BEFORE
TO BE SAD WHEN IT’S TIME TO SAY GOODBYE
WHAT NOT TO EXPECT
TO HAVE OTHERS PICK UP AFTER YOU
TO HAVE A LOT OF PRIVACY TO EVER REGRET YOUR CAMP EXPERIENCE
TO EVER FORGET YOUR CAMP EXPERIENCE
SIGNATURE: ___________________________________________________ DATE: _______________
Camp Amigo Policies
Alcohol
• The possession or consumption of alcohol by anyone regardless of
location is prohibited.
Tobacco
• The use of tobacco by campers is prohibited. The use of tobacco by
adults is only in designated areas and shielded from campers.Illegal Drugs/ Weapons
• The possession of any substance/ weapons will not be tolerated.
Camp Boundaries
• Campers and counselors must stay on designated trails. Campers and counselors must be together in all designated areas of Nantahala Outdoor Center.
Curfew
• Campers must be in their designated cabins at lights out. Counselors
may be outside the cabin but there must be at least two counselors
inside the cabin while campers are asleep.Cabin Assignments
• At no time will male campers be allowed in female cabins or female
campers are allowed in male cabins. Cabins will be kept neat. We are
responsible for damages to cabins. Counselors should report any
damage to staff immediately. The A/C in cabins is set and IS NOT to
be tampered with.Privacy
• Privacy of campers and counselors is important and should be
respected. Avoid any actions, comments or information that may place
the camper or counselor in an embarrassing or uncomfortable
situation. (i.e. comments regarding weight, speech pattern, gender,sex, race, color, religion, etc.) Also remember that this is communal
living and therefore there is no expectation of true privacy.
Touching
• Never touch a camper or counselor on a part of the body normally
covered by a bating suit or in any way that makes them
uncomfortable.
Raiding
• Raiding of rooms is prohibited. Though raids may be considered fun,
they always end up messing up someone’s personal stuff, damagingfacilities, and wasting resources.
Being on time
• Our schedule at camp is very laid back. So on the few occasions we do
have a designated meeting time, it is important that you and your
camper be on time.
Signature: ______________________________________________ Date: _____________
CAMP AMIGO 2018 SCAR MANAGEMENT WORKSHOP MEDICAL RECORD
Therapeutic Massage Medical Record
Name: ___________________________________________________________ Date: __________________________
Address: _________________________________________________________________________________________
Parents Home Phone Number: __________________________ Work Phone Number: ___________________________
Cell Phone Number: _______________________________ E-mail address: ___________________________________
Occupation: _____________________________________ M/F: ____ Age: ____ Date of Birth: ____________________
Best way to contact you: Call home ____ cell ____ work ____ E-mail ____ Text ____
Has your child ever had a therapeutic massage before? Yes, No If yes, how many times? ____
Please indicate any of the following medical conditions/symptoms that you have had:
____ Allergies ____ Fibromyalgia ____ Muscle Strain ____ Angina ____ Frozen Shoulder ____ Osteoporosis ____ Arthritis ____ Headaches ____ Phlebitis/Thrombosis ____ Asthma ____ Heart Disease ____ Pregnancy ____ Auto-Immune Disorder ____ Hepatitis ____ Sciatica ____ Backache ____ High Blood Pressure ____ Scoliosis ____ Bleeding Disorder ____ Infection ____ Seizure Disorder ____ Cancer ____ Kidney Disorder ____ Skin condition/Infection ____ Carpal Tunnel Syndrome ____ Liver Disorder ____ Stroke ____ Chest Pain ____ Lyme’s Disease ____ Varicose Veins ____ Diabetes ____ Meningitis ____ Whiplash Injury ____ Disc Problems ____ Migraines
Please list any significant injuries, illnesses, or surgeries? (Please be specific)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please list any medications you are taking and what condition they are used to treat:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
On the figures at the right, please indicate any areas of pain, tightness, swelling, numbness, injury, or infection. Massage is contraindicated under certain medical conditions. I affirm that I have stated all my child’s known medical conditions and answered all questions honestly. I understand that there shall be no liability on the practitioner’s part should I fail to do so.
Signed: ______________________________ Date: __________ I understand that my child will be receive therapeutic massage by licensed health care massage therapists under the supervision of three instructors. I give my permission as parent/guardian for my child to receive a therapeutic session for their burn scars. Signed: ______________________________ Date: __________
CAMP AMIGO 2018 SCAR MANAGEMENT WORKSHOP MEDICAL RECORD
Burn Medical History
Date of Burn: __________________________
Injury Location(s): __________________________________________________________________________________
Skin Grafts / Donor Sites / Open Wounds? Yes _____ No _____
Location on body ______________________________________________________________________________
What areas can be touched? ________________________________________________________________________
What areas cannot be touched? _____________________________________________________________________
Prostheses? _____________________________________________________________________________________
On the figure below, indicate location of burn(s), skin graft site(s), donor site(s), open wounds, and areas you would not
like touched:
What is/are your chief symptoms: ____ Pain ____ Itching ____ Tightness ____ Weakness ____ Joint Contracture
____ Depression ____ Anxiety ____ Grief ____ Anger ____ Other __________
Additional Information:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Additional information:
• Rain jacket and pants• Baseball cap or wide-brimmed sun hat • Wool/fleece hat (spring and fall)• Fleece jacket (spring and fall)• Gloves (spring and fall)• Extra pair of glasses or contacts if you wear themOptional: Modest cash allowance for souvenir item or snack
Group AdventuresThanks for planning an adventure with NOC! We’re excited to see you. Here are our recommendations on what to bring.When packing, keep the following guidelines in mind:
What to Wear For…
• Long or short-sleeved shirt made out of synthetic or wool material (not cotton)• Board shorts or nylon shorts• Swimsuit• Water shoes or sandals with a heel strap• Sunglasses or glasses with a strap
• Long pants or shorts (longer-length shorts are better suited for wearing a harness while zip lining and for riding a bike)• Long or short sleeved shirt• Socks• Tennis shoes • Closed-toe and closed-back for zip line activities
• Shorts, T-shirt and socks that you don’t mind getting very muddy• Old tennis shoes• Plastic bag to store wet, muddy clothes.
• Long sleeved cotton shirts• Short sleeved T-shirts or comfortable shirts (cotton is okay)• Extra socks• Shorts• Long pants• Underwear• Pajamas • Sports bra• Headlamp or flashlight• Batteries• Water bottle• Toiletries• Necessary prescription medications• Sleeping bag• Sleeping pad (Not necessary in NOC’s cabins, inn or bunkhouse lodging)• Towel• Sunscreen & lip balm• Bug spray• Plastic bag to store wet or dirty clothes• 1 clean outfit for your return trip
Whitewater Rafting Lake, Paddle Boarding & Kayaking:
Zipline, Alpine Tower, Tree Climbing, Mountain Biking Hiking & Wilderness Survival Skills:
Adventure Mud Race:
Overnight Trips:
Strongly Suggested:
• Adjust the number of items you pack according to how many days you will spend with us and what activities you have planned.• NOC’s mountain location means you may experience a wider range of temperatures than you’re used to. Check the forecast, and consider a layering strategy where you can add/remove clothing as needed, especially in the Spring and Fall. Even summer trips can get chilly if it rains, so be prepared.• Please leave your valuables at home—you won’t need jewelry, makeup, fancy clothing or electronic devices.
NOC’s on-site Out�tter’s Store and Wesser GeneralStore carry many of these items. However, there is noguarantee of item or size availability, so please comeas prepared as possible.
01674019.2
For NOC use only
Activity Date: Rsv Party Name:
Activity Time: Rsv #:
Activity Type: # in Party:
RELEASE OF LIABILITY/LIABILITY WAIVER FORM
FULL LEGAL NAME of PARTICIPANT: _________________________________________________________________________
ADDRESS: _________________________________________________________________________________________________
CITY, STATE, ZIP: _________________________________________ PHONE: __________________________________________
EMAIL: _______________________________________________________________
PRINT Full Name of Emergency Contact: ______________________________
Relationship of emergency contact: ____________________________ Phone(s) of Contact Person: __________________________
Activity Participation Acknowledgement
I, the undersigned, hereby acknowledge that I am participating in an activity for which Nantahala Outdoor Center, LLC, a Georgia limited
liability company or one of its subsidiaries (individually and collectively, “NOC”) is furnishing equipment or services and which requires
physical exercise, including, without limitation, rafting, kayaking, swimming, stand-up paddle boarding, rock climbing, hiking, rappelling,
zip-lining, ropes course navigating, or cycling (the “Activity”). By signing this waiver, I certify that I am in good health and physical
condition and do not suffer from any disability which would prevent my participation in the Activity. I agree to abide by any decision of any
NOC employees, organizers, volunteers, directors, representatives, agents, and officers (collectively, the “NOC Parties”) regarding my ability
to safely participate in the Activity. I fully understand that I may injure myself as a result of my participation in the Activity and that certain
injuries may result in death or permanent physical disability. I also acknowledge and agree that my participating in any Activity may be
terminated immediately if any of the NOC Parties believe, in their sole discretion that I am unable to complete the Activity for any reason or
that I am under the influence of alcohol or drugs.
Risk Acknowledgement, Indemnity and Release
In consideration of my participation in the Activity, I hereby assume all risks, known and unknown, associated with participation in the
Activity including, but not limited to, any injuries resulting from falls, contact with other participants, the conditions of Activity sites, bodily
injuries and death. To the fullest extent permitted by law, I hereby agree to indemnify, hold harmless and defend the NOC Parties, as well as,
where applicable, the Tennessee Valley Authority, Ocoee Outfitters Association, the state of Tennessee, the U.S. Forest Service, the United
States of America and other any federal or state governmental agencies or other entities who may have an interest in any river, lake, or other
real property or waterway on which the Activity takes place (individually and collectively, the “Indemnified Parties”) from and against any
and all claims, losses, damages, expenses and other liabilities (including, but not limited to, court costs and attorney’s fees) arising out of or
resulting in whole or in part from my participation in the Activity. I for myself and anyone entitled to act on my behalf, including, but not
limited to my heirs and successors, hereby RELEASE, WAIVE AND FOREVER DISCHARGE the Indemnified Parties from any and all
claims, losses, damages, expenses and other liabilities of any kind arising out of my participation in the Activity even if such claims, losses,
damages, expenses and other liabilities arise out of negligence or carelessness on the part of any or all of the of the Indemnified Parties.
Media Release
I hereby grant and convey to the NOC Parties all right, title and interest I may have in any and all photographs, motion pictures, video
recordings, and any other recordings made during or about the Activity, and the NOC Parties shall have the right to exploit such recordings
throughout the universe, an unlimited number of times, in perpetuity by any and all means and media, now known or hereafter invented.
Medical Emergencies
I hereby give permission to the NOC Parties to contact emergency services for help, whether or not the NOC Parties have contacted my
emergency contact, and give permission to a licensed physician or other licensed medical provider to provide proper treatment, including but
not limited to hospitalization, injection, anesthesia and/or surgery. I hereby RELEASE, WAIVE AND FOREVER DISCHARGE the NOC
Parties from any and all claims, liabilities, causes of action, damages, demands, judgments, executions, liens and costs whatsoever in law or
equity, including, without limitation, liability for death or bodily injuries to any person or damage to any property resulting from any (i)
claims made against medical providers of emergency services under this authorization, or (ii) against the NOC Parties for obtaining
emergency medical services for me pursuant to this authorization and waiver.
______________
Date Your Signature
If you are under the age of 18, your parent or guardian must execute this form on your behalf.
______________
Date Your Parent’s or Guardian’s Signature
Check if you do not want to be occasionally contacted about NOC offers and promotions.
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