OVERNIGHT CAMP REGISTRATION/APPLICATION FORM

All camping slots for the 2008 season have been filled

Our camp is for boys and girls, ages 9 to 13. When you have completed your application, return it to us immediately. If you are waiting to complete the required physical examination, kindly keep the medical page and return the rest of the application with the exception of the medical page. Medical exams will be conducted free of charge by our physician partners at Medwork 84 and Medstar. You will be contacted to arrange a date and time for the physical examination.

Mail completed applications to:

Attn: Jeffrey Aronsky
Smiles are Contagious
60 East 42nd Street
Suite 546
New York, NY 10165

If you prefer to fill the form out by hand, click Here to download a PDF version of this form.

CAMPER FULL NAME:

GENDER:
Male
Female

CAMPER DATE OF BIRTH:
(camper must be between age of 9 and 13 during camping period)

ADDRESS:

PARENT/GUARDIAN NAME:

PARENT/GUARDIAN HOME PHONE NUMBER:

PARENT/GUARDIAN CELL PHONE NUMBER:

PARENT/GUARDIAN EMAIL ADDRESS:

EMERGENCY CONTACTS: Who do we contact if the parent or guardian cannot be reached and the child must be returned home due to homesickness, illness or negative behavior? This must be an adult to whom the child can be released if parent or guardian is unable to pick up their child.

CONTACT NAME:

CONTACT HOME PHONE NUMBER:

CONTACT CELL PHONE NUMBER:

CONTACT RELATIONSHIP:

The following person(s) are NOT allowed to have any contact with my child at any time. If such individual is a natural parent of the child, provide the name and date of the entry of a Court Order, which authorizes your exclusive custody or prohibits such conduct by said parent.

(PLEASE GIVE NAME AND RELATIONSHIP)

THE FOLLOWING INFORMATION WILL REMAIN CONFIDENTIAL:

Are there any activities that your child should not participate in?

Has there been a stressful change in your family this past year?

Yes
No

IF yes, please describe:

How does your child react to new and different surroundings?

Does your child take any medication?

If your child requires medication, then he/she MUST have enough medication for ten days. If your child does not have the sufficient amount or the necessary medicine, you will be contacted and/or early pick up may be required. Please include detailed directions for its use and effects and send it with your child in its ORIGINAL BOTTLE. This medication will be given to the camp medical staff upon arrival.

Does your child have any special needs, physical limitations, allergies, medical or psychological conditions?

How do you hope the SMILES ARE CONTAGIOUS overnight camp will benefit your child?

RULES & REGULATIONS

1. Campers are never to touch another camper or staff member for any reason.

2. Use of bad language or any derogatory remarks at camp is prohibited.

3. Campers must not take or pick up another’s clothes, equipment or belongings. If this happens tell a counselor.

4. Do not bring any of the following items: blow dryers, curling irons, make-up, any aerosol products, spaghetti strap tops, radios, pocket games (gameboys or PSP’s), baseball cards, comic books, pogs, etc.

5. The following items you are permitted to bring and they should be labeled and packed in a duffel bag:

clothing, bedding, towels, sunscreen, and bathing suit.

6. Camp is not responsible for any misplaced, lost or stolen items.

7. A lifejacket and closed toe, rubber soled shoes must be worn at all times while at the lake (NO SANDALS).

8. Parent, guardian, or authorized person must be present during all sign in and sign out procedures. If you are going home early, a note for early camper departure must be mailed or faxed to the camp office. PARENTS MUST SIGN CAMPERS OUT IN THE INFIRMARY WHEN PICKING UP FOR EARLY DEPARTURE.

9. Parents must drop off and pickup in the Pavilion only. Lunch will be served at noon for any early arrivals. Please remain in the Pavilion.

10. Campers may not leave the grounds unless they have been signed out and are leaving with an authorized person. Campers are never to go anywhere by themselves.

11. Campers must attend assigned activities. There is NO SKIPPING.

12. If camper has a disciplinary problem, he or she will be talked to by the cabin counselor. If the problem persists, the camper will be directed to the tracker or camp director. A parent will be called as a last resort. These steps will be followed depending on the severity of the problem.

We agree to the above rules and regulations.

CAMPER’S Signature: _________________________________________

Date: _____________

PARENT’S Signature: _________________________________________

Date: _____________

CAMPER BEHAVIOR/PARENT AGREEMENT RULE

As the parent of ________________________________ I understand that any disruptive behavior, (i.e. fighting, defiance, unwillingness to participate in daily activities, refusing medication, not eating), constitutes necessity for me, the parent, to pick up my son/daughter in any and all of these circumstances. I understand and will comply with these rules if any of these behavior patterns occur. I understand that it is the parent’s responsibility to bring the camper home.

PARENT’S Signature: ______________________________________

Date: ______________

CHALLENGE COURSE PARTICIPATION AGREEMENT - ASSUMPTION OF RISK

1. I (Please print participant’s full name) __________________________________ understand that the Florida Elks Youth Camp's Ropes Challenge Course is an outdoor adventure activity and that certain known and unknown inherent risks may exist in relation to this unique activity.

2. I understand that some, but not all, of the risks may include:

extreme temperature or weather conditions
bruises and/or scrapes to body
risk of falling and/or equipment failure
bee stings or insect bites
emotional distress
heat exhaustion-heat stroke
serious injury
physically difficult conditions

3. I understand that the Florida Elks Youth Camp and Smiles are Contagious operates all programs on a Challenge by Choice basis. I understand that I am free to choose NOT to participate in any activity or PART OF any activity that I do not want to participate in. I understand that I will be fully supported in my choice.

4. I understand that the Florida Elks Youth Camp's Ropes Challenge Course staff will meet professionally accepted standards of care and safety. I understand that safety rules will be discussed throughout the day and it is my responsibility to ensure that I understand and follow all safety guidelines.

5. I understand that it is my responsibility to inform the Florida Elks Youth Camp staff and Smiles are Contagious of any and all physical limitations, liabilities, or injuries including but not limited to: neck and back problems, recent surgery, allergies and any other medical situations.

6. I understand that the Florida Elks Youth Camp and Smiles are Contagious, its staff, employees, independent contractors and associates shall not be held liable or responsible in any way to me for bodily injury, illness (whether mental or physical), property damage or loss. The terms hereof shall serve as a release and assumption of risk for myself and all members of my family. Should the Florida Elks Youth Camp, Smiles are Contagious, or anyone acting on their behalf, be required to incur attorney's fees to enforce this agreement, I agree to indemnify and reimburse them for such fees and costs.

7. Specifically exempted from this release are any injuries caused by the gross negligence of any Florida Elks Youth Camp staff as it specifically relates to the Ropes Challenge Course safety procedures.

8. I HAVE READ, UNDERSTOOD AND ACCEPTED THE CONDITIONS STATED HEREIN AND HEREBY ACCEPT THE CHALLENGE OF THE FLORIDA ELKS YOUTH CAMP ROPES CHALLENGE COURSE PROGRAM.

Participant______________________________________

Date_____________

Witness/Parent/Legal Guardian______________________________________

Date_____________

PHOTOGRAPHIC PERMISSION

Camper’s Name: (First) _________________________
(Middle) _________ (Last) ______________________

The Florida Elks Youth Camp and Smiles are Contagious utilizes photographs and video tapings of campers in their promotional materials.

_____ I hereby give my permission for my child to be photographed or video taped while staying and participating in the activities at the Florida Elks Youth Camp. I also give my permission for those photographs or video tapings to be used without charge by the Florida Elks Youth Camp and Smiles are Contagious in their promotional materials.

____ I DO NOT give my permission for my child to be photographed or video taped by the Florida Elks Youth Camp and Smiles are Contagious in their promotional materials.

______________________________________________ __________

Signature Relationship Date

HEALTH CARE RECOMMENDATIONS TO BE FILLED OUT BY A LICENSED MEDICAL PERSONNEL

NAME OF CHILD:_____________________________________________

DOB:______________

AGE:_________________

SS#: ___________________________

GENDER:___________________

I have examined the above camp participant. Date of last examination:

BP __________ Weight __________ Height __________

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:

______________________________________________________

Current treatment at the time of this report includes:

______________________________________________________

Recommendations and Restrictions at Camp

Treatment to be continued at camp:

______________________________________________________

Medications to be administered at camp (name, dosage, frequency):

______________________________________________________

Known Allergies (food, medication, or other):

______________________________________________________

Description of any limitation or restriction on camp activities:

______________________________________________________

Additional information for health care staff at the camp:

______________________________________________________

Dietary Restrictions

The following restrictions apply to this individual.

[ ] Does not eat red meat
[ ] Does not eat pork
[ ] Does not eat eggs
[ ] Does not eat poultry
[ ] Does not eat seafood
[ ] Does not eat dairy

Other (describe)
______________________________________________________

______________________________________________________

Please give the most recent dates of immunization for:

Vaccines	Dates: Mo/Yr	Vaccines	Dates: Mo/Yr
DTP	__________	MMR	__________
TD (tetanus/diphtheria)	__________	Haemophilus influenza-B	__________
Tetanus	__________	Hepatitis-B	__________
Polio	__________	Varicella(chicken pox)	__________
BCG	__________

Signature of Licensed Medical Personnel

X ____________________________________

Printed: ____________________________________

Title:___________________________________________

Address:
___________________________________________

___________________________________________

___________________________________________

Phone Number:_______________________

Date:__________

OVERNIGHT CAMPCHECK LIST OF NEEDED ITEMS

Please keep this page for your records.

____ 1 SET OF SHEETS FOR A SINGLE BED OR A SLEEPING BAG	____ 7 PAIRS OF SHORTS
____ 1 PILLOW WITH PILLOW CASE	____ 7 SHIRTS (No spaghetti straps)
____ 1 BLANKET	____ 1 PAIRS OF JEANS
____ 2 TOWELS	____ 7 PAIRS OF SOCKS
____ 1 WASH CLOTH	____ UNDERWEAR
____ TOOTHBRUSH	____ PAJAMAS
____ TOOTHPASTE	____ SWIMSUIT
____ BAR OF SOAP	____ HAIR RUBBER BANDS*
____ INSECT REPELLANT	___ 1 PAIR LONG SHORTS
____ SUNSCREEN	____ 1 PAIR OF SNEAKERS
____ SHAMPOO/CONDITIONER	____ 1 PAIR OF OLD SNEAKERS
____ BRUSH/COMB	____ PRESCRIPTION MEDICINE
____ DISPOSABLE CAMERA*	____ PEN/PENCIL*
____ COMBINATION LOCK WITH LONG SHACKLE*	____ ENVELOPES & STAMPS*

*OPTIONAL

DO NOT BRING THE FOLLOWING ITEMS TO CAMP

RADIOS, CD PLAYERS, MP3 PLAYERS, OR T.V.S. NO ELECTRONICS

ELECTRONIC AND/OR VIDEO GAMES (GAMEBOY, ETC)

JEWELRY

CURLING IRONS

MAKEUP, NAIL POLISH

FOOD

FISHING POLES AND FISHING GEAR

TENNIS AND BASEBALL EQUIPMENT

CELL PHONE

FLASHLIGHT

ANY AEROSOL PRODUCTS

SPAGHETTI STRAP TOPS

ROLLER SHOES

SKIRTS – Active games are played

SPECIAL NOTE: As you are leaving camp on Saturday, we are preparing for new campers on Sunday. If you have left any items at the camp, they will have to be discarded Sunday morning.

SOME FACTS ABOUT CAMP

The camp is a secure gated facility requiring a code to gain entry.
Campers may not receive any visitors during camp.
Chaperone teams patrol the camp during the night.
Girls and boys cabins are located in separate areas.
All staff on our property has background checks to insure safety of the children.
Cell phones are strictly prohibited to campers. Phones take away from the camping experience. They will be confiscated and returned at check-out.
Assist your child’s transition to camp by allowing sleep-overs to non-family households prior to camp.
Camp is about meeting new people. Campers will be roomed with other like-aged campers for their six-day adventure at camp. It is a better experience for them not to room with friends or neighbors.
We are an active, outdoor camp, so short shorts, skirts, and spaghetti straps are not allowed.

We look forward to your children attending camp!

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