Emergency Contact other than Parent or Guardian (Required): Name: Relationship:

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1 1 The Episcopal Diocese of North Carolina 20 HUGS Camp Special Needs CAMPER Registration Download form. Complete ALL information on computer then print and sign. This form may be saved on your computer. Cost is $420. $140 is due with application and balance due upon acceptance to camp. Make checks payable to: The Episcopal Diocese of NC Mail completed forms, deposit and current picture if you are a new camper to: Episcopal Diocese of North Carolina Attn: Youth Dept. 200 W. Morgan St., Suite 300, Raleigh, NC Name Goes by _ Gender: Male Female Birthdate Age at time of camp Mailing Address City State Zip Code Camper lives: Independently With Family With Caretaker, Name Phone ( ) Group Home, Name Contact Person Phone ( ) T-Shirt Size (Adult sizes): XS S M L XL XXL address for at least one parent/guardian is required for communication. Contact Name associated with contact Father Home ( ) Work ( ) _ Cell ( ) Mother Home ( ) Work ( ) Cell ( ) Guardian/Caretaker Home ( ) Work ( ) Cell ( ) Emergency Contact other than Parent or Guardian (Required): Name: Relationship: Work ( ) Home ( ) Cell ( ) _ Roommate requests:

2 2 HUGS Camp Health History Form 20 Name Physician Dentist Phone ( ) Phone ( ) Insurance Information Please mail a copy with your registration. Company Subscriber number Diagnosed Conditions: Past surgical procedures: Diet: Regular Diabetic Gluten Free Vegetarian Vegan Other Vision Intact Impaired Wears Glasses Partial Blindness Total Blindness Hearing Intact Impaired Hearing Aid Left Hearing Aid Right Deaf Speech Understandable Difficult to understand No speech Mobility Normal Slow Needs assistance Unsteady on uneven ground Walker Brace Wheelchair Crutches Self-care (feeding, dressing, showering, toileting) Independent Needs Assistance with Bowel Habits Frequency: every day every 2-3 days every 4-5 days Usual time of day for BM: BM routine:

3 3 Name 20 Swimming Independent Needs Assistance Uses floats Doesn t swim Social Skills No difficulties Needs encouragement Has difficulties Behavior Modification Responds best to: Verbal reasoning Going to a quiet place Loss of privileges Other What are the camper s special talents, hobbies, interests? Does this camper need any sleeping aids? (night light, soft music, bedtime routine,etc.) Are there any concerns about this camper s involvement in camp? Signatures Signatures are REQUIRED for ALL items below PARENT/GUARDIAN RELEASE (For campers who need total toileting or bathing care only) I, the parent/guardian of the above named camper, hereby give my permission for him/her to be assisted in toileting by helpers/staff of the opposite gender, as well as those of the same gender. It is understood that cross-gender assistance will only be permitted in the event that it is necessary to give adequate support to the camper. A member of the same gender will also be present. Yes No Not Applicable Signature of Parent/Guardian

4 4 General Release The undersigned do(es) hereby give permission for our (my) child: ( Participant ), to attend and participate in HUGS Camp, sponsored by The Episcopal Diocese of North Carolina. LIABILITY RELEASE: In consideration of The Episcopal Diocese of North Carolina allowing the Participant to participate in youth ministry activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless The Episcopal Diocese of North Carolina, its employees, volunteers and agents (collectively herein the Diocese ) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the youth activities. We (I) the parent (s) or legal guardian (s) of this Participant hereby grant our (my) permission for the Participant to participate fully in youth ministry activities. Furthermore, we (I) [and on behalf of our (my) Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said Diocese to furnish any necessary transportation (within the limitations of Diocesan insurance and the law), food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Diocese for any liability sustained by said Diocese as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto. Medical Treatment Permission: We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree (s) to pay all cost and expenses incurred in connection with such medical and dental services rendered to the afore mentioned youth pursuant to this authorization. Furthermore, we (I) give permission for an adult supervisor to administer any over-the-counter medication, as specified on the Participant s medical form, my child may need during this event. Early Return Home Policy: Should it be necessary for our (my) youth to return home due to medical reason, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility. Photo Release Permission: The undersigned understands that promotional pictures (individual and group) have been / will be taken during these events. I give permission for my child s picture to be used for promotional materials (newsletter, web page, promotional signs, etc.) in highlighting the event. NAMES WILL NOT BE USED. Transportation Permission: The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by and approved ADULT chaperone while attending and participating in activities sponsored by the Diocese. My youth and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation. We (I) the undersigned also, acknowledge that I have reviewed details regarding the event our (my) child is participating in. Parent(s)/ Guardian(s) Signature(s) /

5 5 HUGS Camp Medication Form Name 20 Takes No Routine Meds Allergies Completed form MUST be submitted with registration, even if medications may change. Medication Dosage Administration Times (ex. Synthroid) Include vitamins and supplements (ex. 150mcg once a day) 7:30 am 8 am - Breakfast 10:00 am 12 noon - Lunch 3:00 pm 5 pm - Dinner 8 pm - Bedtime Other Treatment Body Area Times 7:30 am 1:00 pm Bed time Other Over-the-Counter Medications that may be taken IF needed Yes No Yes No Tylenol (Acetaminophen) Anti-nausea medicines Motrin (Ibuprofen) Laxatives Aleve (Naproxen) Mineral Oil Benadryl (for allergic reactions) Sunscreen Antihistamines (for allergic reactions) Insect repellent Signature of Parent/Guardian Signature of Nurse at Camp

6 6 HUGS Camp Community Covenant For Campers Name 20 It is not acceptable for members of The HUGS Camp Community to: 1. Touch others in a sexual way. 2. Smoke, drink alcohol, or take pills from someone besides the nurse. 3. Steal or be violent. 4. Go into cabins of the opposite sex. 5. Have fireworks, guns, knives or any other weapons. 6. Show disrespect to fellow campers, staff, property of others, or property of The Summit; 7. Leave the camp area without your helper. This is a Community Covenant, and a violation of this covenant is a violation of the community. All violations will be dealt with appropriately by HUGS Camp staff. Possible consequences may include notification of the violator's parents and/or rector, and the violator may be asked to leave HUGS Camp. *I have discussed this covenant with my camper: Signature of Parent/Guardian

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