CAMP NEOFA. Northeast Odd Fellows Association Of the Independent Order of Odd Fellows

Transcription

1 CAMP NEOFA Northeast Odd Fellows Association Of the Independent Order of Odd Fellows Member Jurisdictions: CONNECTICUT. MAINE. ATLANTIC PROVINCES. MASSACHUSETTS. NEW HAMPSHIRE. QUEBEC. RHODE ISLAND. VERMONT CAMPER APPLICATION 2015 Ages 8-14 All questions MUST be answered and the application signed. PLEASE TYPE OR PRINT. Name Age DOB School Grade (Last) (First) (Initial) Address (Street Number and Name) (Apt. Number) Telephone # (City/Town) (State/Province) (Zip/Postal Code) Parent/Guardian Telephone # Name/Address of Lodge or Individual Paying Fee Are you a member of organization Yes No Contact Person Telephone # Address RESERVATIONS A CAMPING WEEK begins SUNDAY AT NOON, after lunch ends SATURDAY AT NOON A fee of $10 per day for early drop off, late pick up, or date change CAMP NEOFA is open for five (5) weeks CHECK THE WEEK(S) THE CAMPER WISHES TO ATTEND Staff/CIT Week ( ) June 29 July 2 FOR 8 14 YEAR OLDS 1st ( ) July nd ( ) July rd ( ) July th ( ) July 26 August 1 CAMP NEOFA RESERVES THE RIGHT TO REFUSE ANY CHILD WHOSE MEDICAL/BEHAVIORIAL NEEDS CANNOT BE MET ( ) RESIDENTIAL CAMP FEE $300.00/ WEEK ( ) DAY CAMP FEE $150/ WEEK A transferable but Non-refundable fee of $75.00 must accompany application INDIVIDUAL CAMPER FEES MUST BE PAID BY BANK CHECK or MONEY ORDER, (see reverse side)

2 HEALTH INFORMATION Home Physician Telephone # Physician s Address Name of Insurance Company: Camper s Insurance/Medicare Number: This information must be filled out in addition to the Health Form that must be filled out by Physician prior to coming to camp. IN THE EVENT OF ACCIDENT OR ILLNESS, INDIVIDUAL S INSURANCE WILL TAKE PRIORITY OVER CAMP NEOFA S INSURANCE (Camp NEOFA and/or Northeast Odd Fellows Association are not responsible for any nonwork related medical expenses) X (Parent/Guardian Signature) PLEASE INCLUDE A COPY OF CAMPER S MEDICAL CARD WITH APPLICATION PARENT / GUARDIAN CONSENT My permission is granted herewith for the attendance of my ( ) Son, ( ) Daughter, ( ) Ward, at Camp NEOFA, Montville, Maine. Should any accident or illness befall them, I understand that proper medical attention will be given and if further participation at Camp NEOFA is restricted by the Attending Physician, I am willing that he/she be returned home at my expense. Should he/she be unwilling to cooperate and become irresponsible and/or disruptive, I authorize that he/she be returned home before the session is concluded, at my expense. IN THE EVENT OF AN EMERGENCY, IF YOU ARE NOT AVAILABLE, PLEASE NOTIFY: Name Relationship: Address Work Phone: ( ) Home Phone: ( ) Signed Parent/Guardian Date Signed Emergency Contact Date Send completed application, holding fee ($75) or registration ($300 OR $150), and copy of camper s medical card to: BEFORE JUNE 1: AFTER JUNE 15: Alice Bennett, Director of Camping Alice Bennett, Director of Camping PO Box 122 PO Box 101 Shelburne, VT Liberty, ME 04949

3 Dear Parents: This year we are asking all families to fill out the application on the attached form. All information will be kept strictly confidential and no names will be used for data purposes. This information will help us to secure funding to help with the costs of food that is served. We thank you in advance for your cooperation. Camp NEOFA

4 CAMP NEOFA MEAL FUNDING PROGRAM APPLICATION Please complete this form and return with Camp Applications. One form may be completed by all siblings. Camper First Name Camper Last Name Grade School (camp use only) Food Stamp ID (numbers & letter) TANF ID (numbers & letter) Foster Child Yes No Camper First Name Camper Last Name Grade School Food Stamp ID (numbers & letter) TANF ID (numbers & letter) Foster Child Yes No Camper First Name Camper Last Name Grade School Food Stamp ID (numbers & letter) TANF ID (numbers & letter) Foster Child Yes No TOTAL NUMBER IN HOUSEHOLD (all adults + children) All HOUSEHOLD (not just family) members not listed above must be listed below. This includes adults and non-camp children, who live in the HOME. Names of Other Household Members Current Monthly Income All Other Household Members Monthly Earnings From Work (Before Deductions) Job 1 Monthly Welfare, Child Support, Alimony Monthly Payments from Pensions, Retirement, Social Security Monthly Earnings from Job 2 or any Other Monthly Income Check if NO Income SIGNATURE: An adult household member must sign the application with the last 4 digits of his/her social security number before it can be approved. PENALTIES FOR MISREPRESENTATION: I certify that all of the above information is true and correct and that the food stamp or TANF number is correct or that all income is reported. I understand that this information is being given for the receipt of Federal funds; that institution officials may verify the information on the statement and that the deliberate misrepresentation of the information may subject me to prosecution under applicable State and Federal laws. Signature of Adult Date Last 4 Digits of Social Security# I have no SS # Privacy Act Statement. Unless you list the child s food stamp or TANF case number, Section 9 of the National School Lunch Act requires that you include the last 4 digits of the social security number of the household member signing the application or indicate that the household member does not have a social security number. You do not to list a social security number, but if the last 4 digits of a social security number are not listed or an indication is not made that the adult household member signing the application does not have a social security number, we cannot approve the application. The last 4 digits of the social security number may be used to identify the household member in verifying the correctness of information stated on the application. This may include program reviews audits, and investigations and may include contacting employers to determine income, contacting a food stamp or TANF office to determine current certification for food stamps or TANF benefits, contacting the State employment security office to determine the amount of benefits received and checking the documentation produced by the household member to prove the amount of income received and checking the documentation produced by the household member to the amount of income received. These efforts may result in a loss or reduction of benefits, administrative claims, or legal actions if incorrect information is reported.

5 CAMP NEOFA Application / Health History Form Montville, Maine 2015 Camping Season Mail this form no later than 6/15/15, to: Alice Bennett PO Box 122; Shelburne VT Dates will attend camp: to Month/Day/Year Month/Day/Year Camper Name: First Middle Last Male Female Birth Date Age on Arrival at Camp To Parents/Guardians: Please follow the instructions below. If additional space is needed, please attach separate sheets. 1) Complete this form and make one copy. 2) Send the original, signed form to the above address by the requested date. 3) Have the last page (Health Care Recommendations by Licensed Medical Personnel) completed by a licensed medical professional a medical exam MUST have been conducted within 12 months of camp attendance. Camper s Home Address Street Address City State Zip /Postal Code Parent/Guardian with legal custody to be contacted in case of injury/emergency: Name Relationship to Camper Phone #(s) address Home Address Street Address City State Zip/Postal Code Second Parent/Guardian or Other Emergency Contact: Name Relationship to Camper Phone #(s) address Additional Contact in Event Parents/Guardians cannot be reached: Name Relationship to Camper Phone #(s) Allergies: No Known Allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other ( please describe below what the camper is allergic to and the reaction seen) Restrictions: I have reviewed the programs of the camp and feel the camper can participate without restrictions. I have reviewed the programs of the camp and feel the camper can participate with the following restrictions or adaptations: (please describe below) Medical Insurance Information: The camper is insured by family medical/hospital insurance. Yes No Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable. Insurance Company Policy Number Parent/Guardian Authorization for Health Care: This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give my permission to the physician to hospitalize, secure proper treatment for and order injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a need to know basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child s health record from providers who treat my child and these providers may talk with the program s staff about my child s health status. Signature of Custodial parent/guardian Date Relationship to Camper If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Camp NEOFA and/or Northeast Odd Fellows Association is not responsible for any non-work related expenses. 1

6 MEDICATIONS BEING TAKEN: Please list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration. This person takes NO medication on a routine basis. This person takes medications as follows Med #1 Dosage Specific time taken each day Reason for Taking: Med #2 Dosage Specific time taken each day Reason for Taking: Med #3 Dosage Specific time taken each day Reason for Taking: Attach additional pages for more medications. Identify any medications taken during the school year that participant does/may not take during the summer. GENERAL QUESTIONS: (Explain yes answers below. Has/does the participant: YES NO YES NO 1) Had any recent injury? 17) Ever been dizzy during or after exercise? 2) Have a chronic or recurring illness/condition? 18) Ever had high blood pressure? 3) Ever been hospitalized? 19) Ever been diagnosed with a heart murmur? 4) Ever had surgery? 20) Ever had back problems? 5) Had a recent illness? 21) Ever had problems with joints (knees,ankles)? 6) Had a recent infectious disease? 22) Have an orthodontic appliance being brought 7) Ever had a head injury? to camp? 8) Ever been knocked unconscious? 23) Have any skin problems (itching,rash,acne)? 9) Have asthma, wheezing, shortness of breath? 24) Had mononucleosis in the past 12 months? 10) Wear glasses, contacts or protective eyewear? 25) Had problems with diahrrea/constipation? 11) Ever had frequent ear infections? 26) Have problems with sleepwalking? 12) Have diabetes? 27) If female, have abnormal menstrual history? 13) Have seizures? 28) Have a history of bedwetting? 14) Have headaches? 29) Ever had an eating disorder? 15) Ever passed out during or after exercise? 30) Ever had emotional difficulties for which 16) Ever had chest pain during or after exercise? professional help was sought? 31) Traveled outside country in past 9 months? PLEASE EXPLAIN ANY YES ANSWERS, NOTING THE NUMBER OF THE QUESTIONS. 2

7 Which of the following Please give all dates of immunizations for: 2 Has the participant had? Vaccine Dates Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Mo/Yr Measles DTP Chicken Pox TD(Tetanus/Diphtheria) German measles Tetanus Mumps Polio Hepatitis A MMR Hepatitis B or Measles Hepatitis C or Mumps or Rubella TB Mantoux Test Haemop[hilus influenza B Date of Last Test Hepatitis B Result: Positive Negative Varicella (chicken pox) USE THIS SPACE TO PROVIDE ANY ADDITIONAL INFORMATION ABOUT THE PARTICIPANT S BEHAVIOR AND PHYSICAL, EMOTIONAL OR MENTAL HEALTH ABOUT WHICH THE CAMP SHOULD BE AWARE. Mental, Emotional and Social Health: Check Yes or No for each statement. Has the camper: YES NO 1) Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)? 2) Ever been treated for emotional or behaviorial difficulties or eating disorcer? 3) During the past 12 months, seen a professional to address mental/emotional health concerns? 4) Had a significant life event that continues to effect the camper s life? PLEASE EXPLAIN YES ANSWERS IN THE SPACE PROVIDED. The following non-prescription medications may be stocked in the camp Health Center and are used on an as-needed basis to manage illness and injury. Cross out those the camper should not be given. Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed) Antihistamine allergy medicine Guaifenesin cough syrup (Robitussin) Diphenhydramine antihistamine allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Sort throat spray Generic cough drops Lice shampoo or cream (Nix or Elimite) Antibiotic cream Calamine lotion Aloe Laxatives for constipation (Ex-Lax) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto- Bismol) 3

8 Name of Family Physician Phone Address Name of Family Dentist/Orthodontist Phone Address Health Care Recommendations by Licensed Medical Personnel: I examined this individual on (ACA accreditation requirements specify exams within 12 months of camp attendance). BP Height Weight In my opinion, the above applicant is is not able to participate in an active camp program. The applicant is under the care of a physician for the following conditions: Recommendations and Restrictions at Camp: Treatment to be continued at camp Medications to be administered at camp (name, dosage, frequency) Any medically-prescribed meal plan or dietary restrictions Known allergies Description of any limitation or restriction on camp activities Additional information for health care staff at the camp SIGNATURE OF LICENSED MEDICAL PERSONNEL Printed Title Address Phone Date 4