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?

FLORIDA ELKS YOUTH CAMP, INC.
SMILES ARE CONTAGIOUS

CAMPER HEALTH HISTORY FORM

TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN

Please answer all questions below. If you answer YES to any questions, please explain.

General Health History

1. Does your child have any past or current conditions, including injuries, (physical, mental, or psychological) that may affect his or her stay at camp?

2. Are there any activities that your child will not be able to participate in during camp? Please see the Camp Activity List at the bottom of page 6.

3. Please list any medications your child is currently taking, including all over-the counter medications. Please note that all medications your child will be using at camp must be brought in the original, labeled package.

4. Does your child have any problems sleeping (sleep walking, bedwetting, or sleep apnea, etc.)?

5. Has your child traveled outside of the United States in the Past 9 months? Please specify location.

6. Has your child ever been hospitalized?
   

7. Has your child ever been treated for or diagnosed with Asthma, diabetes, or seizures?

8. Has your child ever been treated for emotional behavioral difficulties or an eating disorder?

9. During the past twelve months, has your child seen a professional to address mental/emotional health concerns?

10. Has your child ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity Disorder (ADHD)?

11. If there is any additional medical information you think is important or that may affect the camper’s ability to participate in the camp, please explain below.

Parent or guardian filling out form
(please print):___________________________________________

Signature:__________________________________ Date:____________________

FLORIDA ELKS YOUTH CAMP, INC.
SMILES ARE CONTAGIOUS

AUTHORIZATION & WAIVER BY PARENT (S) OR LEGAL GUARDIAN (S) OF MINOR CHILD

Each of the undersigned parent (s) or legal guardian (s) of the minor child named below states as follows:

NAME OF CHILD:

SS#

I am aware that normal and usual athletic and sports-related activities have certain inherent risks and may cause injury to participants. However, I want my child/ward to participate in the Florida Elks Youth Camp, Inc. Smiles are Contagious (“the Camp”) sponsored lessons, practices, games exhibitions, tournaments, competitions, and other events (“the Activities”), and I give my unqualified permission and consent for my child/ward to participate in the Activities, subject only to any specific limitations noted below.

My child/ward has the necessary skills and is able to participate in all reasonably anticipated aspects of the Activities except as noted below. The nature of the Activities has already been fully disclosed to me, and any brochure, flyer, or announcement relating to the Activities is expressly made a part of this Authorization & Waiver.

I, on behalf of my child/ward hereby indemnify, release, hold harmless, and forever discharge the Camp and it’s agents, employees, officers, directors, affiliated, successors, and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages, and liabilities of every kind and nature, whether known or unknown, in law or equity, that I or my child/ward ever had or may have, arising from or in any way related to my child/ward’s participation in any or the Activities conducted by, on the premises by or at the request of the Camp. The undersigned specifically agrees that either Lake County or Marion County, Florida shall be the appropriate venue to litigate any controversy that arises out of or relates to this Authorization & Waiver or the alleged breach of it and that cannot be settled by the parties alone.

The Florida Elks / Smiles are Contagious Youth Camp reserves the right to refuse admission of or limit the activities of a camper with a communicable disease.

I understand that an acute or emergency condition or illness involving my child/ward might arise during my child/ward’s stay at the Camp. In such circumstances, in the event that I am unable to be contacted, I authorize the transportation and treatment of my child/ward if, in the opinion of an attending medical professional or the Camp’s staff, such treatment is warranted, I further hereby give my permission for the Camp’s medical professional to treat the minor daily injuries that my child/ward might receive.

This Authorization & Waiver is binding upon me, my heirs, executors, legal representatives, successors, and assigns. The provisions of this Authorization & Waiver will continue in full force and effect even after the termination of the Camp whether by agreement, by operation of law, or otherwise. This Authorization & Waiver is governed by the laws of the State of Florida and it is intended to be as broad and inclusive as is permitted by those laws. If any provision of this Authorization & Waiver is held invalid or enforceable by a court of competent jurisdiction, the remaining provisions will continue to be fully effective. This Authorization & Waiver contains the entire agreement between the undersigned and the Camp, and supersedes any prior written or oral agreement between them concerning the subject matter of this Authorization & Waiver. The provisions of this Authorization & Waiver may be waived, altered, amended, or repealed, in whole or in part, only upon the prior written consent of all parties.

PLEASE PRINT:

Medical conditions: My child/ward is subject to the following allergies or medical conditions, and I authorize the Camp to disclose such allergies or medical conditions to a physician in the event my child/ward should require emergency medical care (describe allergies or medical conditions with specificity.):

Medications: My child/ward is currently taking the following medications:

Medical Insurance Company Name:

Medical Insurance Policy Number:
(PLEASE ATTACH PHOTOCOPY OF MEDICAL CARD)

Prohibited activities: As a result of the medical conditions described above, or for other reasons, I do Not want my child/ward to engage in any of the following activities (describe with specificity):

I am of lawful age and legally competent to sign this Authorization & Waiver. I understand the terms of this Authorization & Waiver, and I have willingly signed it as my own free act.

PARENT ONE

Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

SIGNATURE: _____________________________________

Date:_______________________

Relationship to child: _______________________

PARENT TWO

Name:

Address:

Home Phone:

Work Phone:

Cell Phone:

SIGNATURE: _____________________________________

Date:_______________________

Relationship to child: _______________________

If the child has two parents or legal guardians, both must fill in the information requested above and sign the Authorization & Waiver.

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: ______________