Kingdom Kamp 2016 Guardian Authorization (Kamper s Name).. has my permission to engage in all prescribed Kingdom Kamp activities, except as noted by his/her physician. I hereby give permission to the Kingdom Kamp staff to administer first aid and medication(s) as needed. I also give permission to the physician selected by the Kingdom Kamp Dean and/or Director to order any necessary examination and/or treatments for the health of my kamper. In the event that I cannot be reached in case of an emergency, I give permission to the physician selected by the Kingdom Kamp Dean and/or Director to hospitalize and secure proper treatment for the kamper named above. Signature of Legal Guardian: Witness: (Note: Witness CANNOT be an immediate family member or other relative.) Covenant of Behavior I, (signature), agree that as a participant in a Rio Texas Conference of The United Methodist Church camping event, I am expected to follow certain conduct standards. I will not bring alcohol, tobacco, illegal drugs or firearms to camp, nor will I do not engage in inappropriate sexual behavior, nor will I intentionally cause the destruction of camp property. I understand that failure to comply with the above will result in my expulsion from camp and possible suspension from future Rio Texas Conference events. I also agree not to bring any items that may interfere with the purpose of camp (such as fireworks, skateboards, stereos, CD players, cell phones, laptop computers or other electronic devices). I am aware that the camp will be providing my meals and that I am not allowed to bring any personal food items, have food sent or delivered to camp, or take food or drink into camp sleeping areas. I agree to follow the daily schedule arranged for the event at all times, and at no time will I leave the event site. I understand that there will be no visitors allowed (including family and relatives) while camp is in progress and that there will be no visitation in rooms designated for the opposite sex. If I should not act in accordance with this covenant while attending camp, I realize that I may be disciplined at the camp Dean s discretion, up to expulsion from camp and suspension from future Rio Texas Conference events. By my signature on the registration form for this event, I am indicating that I have read this covenant and accept my end of the agreement, with the expectation that my camp experience will enhance my spiritual growth and enjoyment. I understand that final acceptance of my attendance is determined at registration check-in by factors concerning medication and behavior. Upon my arrival at camp or at any time during camp, if the Dean, Camp Director or Nurse determines a change in my eligibility status, I could be sent home. 1
Camper Information Form To be filled out by Parent/Guardian or Caregiver 1. Name of Camper: Camper s Height: Camper s Weight: Medical Insurance Provider: Group #: Insured s ID#: Insurance Provider Phone: Name of Primary Physician: 2. If any of the following conditions apply, please provide specific information: Seizures (please include type): Date of Last Seizure: Balance Problems: Bowel Problems: Bladder Problems: Corrective Devices Needed: Does your camper wear Depends? yes no If yes: During the day At night (check both if both apply) NOTE: If yes, please provide an adequate supply of Depends for the weekend. 3. Please write a brief paragraph about your camper. Tell us something about his/her family, hobbies, recreation likes and dislikes, and any additional information that will help staff get to know your camper before Kingdom Kamp begins. 3
4. Behavioral Problems: Please describe FULLY any behavior problems that your camper has, even if the behavior has only occurred once. This information is important for assigning cabin mates and keeping your camper safe while at Kingdom Kamp. 5. Emergency Contact Information: (This person MUST be reachable during the duration of Kingdom Kamp) Name: Address: Primary Phone: Relationship to Camper: City/State/Zip: Alternate Phone: 6. Permission to Photograph: Yes, I give permission for my photograph/image to be used for camp promotion. No, I do not give permission for my photograph/image to be used for camp promotion. Participant Signature Date Parent/Guardian Signature Date 7. Additional comments/information that would be helpful for Kingdom Kamp staff to know: To the best of my knowledge and belief, the information that I have indicated on this form is correct. I also give permission for the Dean and/or Director of Kingdom Kamp to obtain any necessary medical treatment for the above named camper. Name of Legal Guardian (printed): Legal Guardian Signature: 4
Kingdom Kamp Personal Medication List 2016 MUST be TYPED by Parent, Guardian, or Caregiver Kamper s Name: Prescription Medication Purpose or Reason Prescribed Dose Time(s) of Day Form (liquid, tablet, capsule) Special Instructions Over-the- Counter Medication Purpose or Reason Taken Dose Time(s) of Day Form (liquid, tablet, capsule) Special Instructions Signed: Received by: Parent, Guardian or Caregiver Kingdom Kamp Registered Nurse 5
KINGDOM KAMP PHYSICIAN FORM This form MUST be completed and signed by camper s physician. 1. What is the nature and degree of the camper s disability? List both primary and secondary handicap: 2. All Kingdom Kamp activities are modified to suit the needs and abilities of campers and are closely supervised. In which activities can your patient participate? Hiking: YES NO Swimming: YES NO Please specify any activity limitations for your patient: 3. Allergies: List all known allergies; describe reaction and management of the reaction. Medication Allergies: Food Allergies: Other Allergies: Reaction and management: 4. Diet and Nutrition: Eats a regular diet Lactose intolerant / Dairy-free Other (specify): Diabetic / No added sugar Gluten Intolerant / Wheat-free 5. Health History: * Please check all that apply Asthma Diabetes Sleepwalking Bed Wetting Recent Hospitalization (last 6 months) Recent Injury Bowel Incontinence Other Heart Problems Chronic Illness Migraines Seizures: date of last seizure Urinary Incontinence Wears Glasses or Contacts Gait Problems: assistive devices needed Please further explain any items check above: (continued on next page) 6
6. Since last health exam, has the patient: Been exposed to a contagious disease? YES NO Had a condition requiring medical attention? YES NO Been treated in a hospital or emergency room? YES NO Please explain any yes answer to the above questions and include dates: 7. The following non-prescription medications may be stocked in the nurses station and used on an as-needed basis to manage illness and injury. Cross out those the patient should not be given: Acetaminophen (Tylenol) Aloe Antibiotic Cream Antihistamine/Allergy Medicine Bismuth Subsalicylate (Pepto-Bismol) Benadryl Calamine Lotion Chewable Antacid Ibuprofen Robitussin DM Robitussin Cough Drops Sudafed PE Please include additional information that is needed to care for this patient while at Kingdom Kamp: Licensed Physician s Signature: Licensed Physician s Printed Name: Address: City: State: Zip: Phone: Fax: 7