August 4 -August 7, 2016

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1 Minnesota District Royal Rangers DISCOVERY LEADERSHIP TRAINING CAMP THE WOODS AT LAKE PLACID PILLAGER, MN August 4 -August 7, 2016 PURPOSE OF THIS CAMP Discovery Training Camp will provide boys with training using merit skills. This merit-based camp is designed for boys (grades 3-5) AND THEIR LEADERS. Older Ranger boys may attend as junior leaders with approval from the Camp Commander. WHO CAN ATTEND? Royal Rangers who have with written permission from their parents and: 1. Have completed grade 3 or above 2. Should have an outpost leader and or legal guardian attend MEDICAL EXAMINATION Rangers: Please fill out the enclosed Minnesota District Royal Ranger Activity Emergency Medical Information and Authorization Form and bring it to the camp with you. Leaders: please fill out the enclosed Adult Verification Form, have your Pastor sign it and bring it with you to the camp. REGISTRATION FEE A $25 non-refundable fee must accompany this application. The registration cost is $125 if received by July 1 st, and $175 by July 14 and $200 after July 15. This fee includes all meals, the DTC T-shirt. If for any reason you are unable to attend the camp, you must notify Todd Wille District Training Coordinator TWO WEEKS prior to the camp to receive a refund. Discounts include: 1. A $25.00 discount is available for Chartered Outposts. Todd Wille 3625 Power Dam Rd NE Bemidji MN An information packet will be sent to you upon receipt of the camp application.

2 Minnesota District Royal Ranger Leadership Training Academy The Woods at Lake Placid: Pillager, MN Dear Ranger, Ranger Parent or Ranger Leader: Thank you for your interest in the Minnesota District Royal Ranger Training Camps! Our camps assist boys, young men and adults who are interested in developing leadership and camping skills. If you are interested in advanced training, and encouraging fun and safety in the outdoors please sign up for this event at The Woods at Lake Placid in Pillager, Minnesota. The process begins with this application. Please follow the instructions below. Once the application has been received, you will be sent an information pack about your camp(s). This will include the camp schedule(s), all camp prerequisites and everything you will need to bring. We are excited that you will be joining us at this year s Leaders Training Academy! INSTRUCTIONS: Please fill out the Camp Application 1. Fill in the Applicant Information. 2. Fill in the Church Information. 3. Select the desired camp(s). If a Ranger selects more than one camp, please make sure the dates do not conflict. Also, there will be a $20.00 discount for each additional camp. 4. Please include at least the minimum deposit of $25.00 for each camp. (Note: a deposit is required.) 5. Fill out the Medical Release form. 6. Complete the additional information below if required. 7. Return this application and medical form to the address below. PHYSICAL EXAM: Participation in the following camps may include strenuous outdoor activities: Honor Guard Camp Junior Canoe Expedition Therefore, we require that a Ranger has received at least a Sports Physical within the past year. After he receives the physical exam, please sign the following statement: After consultation with my son s physician, I know of no physical reason that would restrict my son from participation in any camp activities. Parent s signature In the event your son receives his exam after this application has been submitted, he must bring a statement from your physician when registering at the camp. Your son will not be able to participate without an exam. For more information about each camp go to the website: Applicant Information Name: Address: City: State: Zip Code: Phone: ( ) Age of Birth: T-shirt size: Youth Men s Church Information Name: Address: City: State: Zip Code: Church Phone: ( ) Pastor: Phone: ( ) Junior Camp Information (check the desired camps) Early registration due by July 1 Deposit Amount: Week 1: Aug 4 Aug 7, 2016 Cost: $ ea* Honor Guard Camp $ Week 1: Aug 4 Aug 7, 2016 Cost: $ ea* Discovery Training Camp $ Big Adventure Camp (FCF) $ Week 2: Aug 11-14, 2016 Cost: $ ea* Junior Training Camp $ Junior Shooting Sports Camp $ Junior Canoe Expedition $ Junior Spirit Challenge Camp $ REGISTRATION DUE JUNE 12 Leader s Camp Information Registration due by July 15, 2016 Deposit Amount: Session 1: Aug 12-13, 2016 Cost: $75.00 Ranger Basics, Ranger Essentials $ NO DISCOUNTS Early Registration Discount before July 1st $50.00 Discount $ Registration between July 2 14 $25.00 Discount $ Total Registration Amount $ *Charter Membership Discount ($25 per camp) $ Discounts ($20 for 2 nd )$ Total Camp Fees $ Deposit Enclosed $ Mail all registrations to: Todd Wille Minnesota District Royal Ranger Training Camps 3625 Power Dam Rd NE Bemidji MN For Official use only: : Check # Amount: $

3 Parent(s): Please completely fill out and sign this form. For your son s protection and safety, he will not be able to participate in any Royal Ranger or Minnesota Boys District event without it. Minnesota District Royal Ranger 2016 PERMISSION / EMERGENCY MEDICAL AUTHORIZATION For all boys and youth (Kindergarten to 12 th grade) under 18 This medical emergency form MUST be signed by a parent or guardian, and accompany the minor who wishes to participate in the Minnesota District Boys/Royal Ranger event. Child s Name: of Birth: Street Address: Home phone: ( ) City / State / Zip: Father s Name: Work / Cell phone: ( ) Mother s Name: Work / Cell phone: ( ) Family Doctor: Office phone: ( ) Insurance Company: Policy Number: MEDICAL QUESTIONNAIRE Please answer ALL of the following questions. EXPLAIN any YES answers completely in the space provided below. Does your son have or is currently being treated for: Yes No 1. Any injury/ illness or taking any form of Yes No 12. Has your son ever had any operations? medication? Yes No 2. Asthma? Yes No 13. Is there any family history of any disease? Yes No 3. Allergies to any medication? Yes No 14. Has your son had any Childhood Diseases (i.e. Yes No 4. Hay fever? measles, mumps, chicken pox, etc)? Yes No 5. Other known allergies? Yes No 15. Does your son ever sleepwalk? Yes No 6. His tonsils removed? Tylenol Yes No 7. His appendix removed? What may we give your son for pain or fever? Aspirin Yes No 8. Require a special diet? Ibuprofen Yes No 9. Any chronic medical problems (i.e. cardiac, respiratory, kidney, seizure or other problems)? Yes No 10. Color blindness? Yes No 11. ADD or ADHD? (Is he on medication?) How would you classify your son s swimming ability? In addition to the above explanations, list any other medical considerations not mentioned above? What is the date of your son s last physical? What is the date of your son s last tetanus shot? Beginner Intermediate Advanced Person(s) to contact in the event of an emergency: Name: Phone: ( ) Name: Phone: ( ) I have read and approved the included information. You have my permission for my child to attend the camp and to participate in its activities. I, acting on my own behalf, also release the Minnesota District Boys/Royal Rangers and/or The Woods at Lake Placid, its agents, assigns, staff, employees as well as volunteer workers from any liability whatsoever arising out of property damage or loss as well as any injury, sickness or death which may be sustained by my child as the result of any participation in any camp activity. I am aware of the risks associated with participating in camping activities and accept participant s participation with full awareness of these risks. I give my permission for the camp medical personnel to treat the listed participant in the event of a minor illness or minor injury. In case of emergency, and when I am unable to be contacted, I hereby give permission to the local physician selected by the camp to hospitalize, secure proper treatment for, order injection, anesthesia, or surgery for my child. I authorize the MN District Royal Rangers to use our child s likeness in photographs or video in any and all of its publications and in any and all other media. I will make no monetary or other claims against the District for the use of such photos or videos. I authorize camp personnel to inspect camper s belongings to see that they have not brought any prohibited or illegal items. I understand that if my child misbehaves and violates the camp rules, I may be called to pick him/her up. Signature of parent or legal guardian Print name

4 Part I: For the Senior Pastor: ADULT VERIFICATION FORM Minnesota District Boys/ Royal Ranger STATEWIDE EVENTS For all person 18 years and older Please completely fill out and sign this form. The purpose of the document is to promote a safe environement for all children attending this event only. He / she will not be able to participate in any Royal Ranger District event without this form. This form MUST be signed by a senior pastor or a staff pastor designated by a senior pastor and accompany the adult who wishes to participate in this Minnesota District Boys/Royal Ranger event. Any person without this document will be asked to leave. NAME PHONE ( ) ADDRESS CITY STATE ZIP CHURCH CITY I am an adult serving the following outpost: Royal Ranger Outpost # or Church Name Pastor s Certification of Adult: I am personally acquainted with the applicant and a background check is on file for this individual. In my opinion, he/she is of appropriate character to be with young people. I know of no facts or allegations that raise any question concerning his/her suitability for participating with minors. Pastor s Signature of Affirmation (No photocopied signatures will be accepted BLUE INK ONLY) Pastor s name and position (please print) Church name (please print) of Pastor s Signature An original copy with an original signature, must be submitted at registration when arriving at the event. One application must be submitted for EACH ADULT and is valid for only this event. Part II: For the Applicant: Permission to Use Image or Likeness: I authorize the MN District Royal Rangers to use my likeness in photographs or video in any and all of its publications and in any and all other media. I will make no monetary or other claims against the District for the use of such photos or videos. Signature Print name 1315 PORTLAND AVE S MINNEAPOLIS, MN PHONE (612) FAX (612)

5 Minnesota District Royal Ranger EMERGENCY MEDICAL AUTHORIZATION For Adults Leaders Ranger s Name Street Address City/State/Zip Spouse Names Family Doctor Insurance Company of Birth Phone ( ) Soc Sec # Work Phone ( ) Office Phone ( ) Policy Number MEDICAL QUESTIONNAIRE Please check you have any difficulty with: Asthma Heart Trouble Eyes, ears, nose throat Fainting spells Allergies Lungs Digestion Convulsions Allergies to medication Hernia Diabetes ADHD or similar Describe if checked: Please answer the following questions: Swimming ability (please circle one): Cannot swim / Beginner / Intermediate / Advanced I can take the following (please circle which are applicable): Aspirin / Tylenol / Ibuprofen Family history of disease: Do you require a special diet? Any condition now requiring regular medication? Operations of serious injuries (list injury and date)? Other chronic medical problem or other medical considerations not listed above? Any restrictions of activities for medical reasons? of last Tetanus shot: (DATE) of last physical: (SIGNATURE)

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