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2008 Camper application |
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PARTICIPANT INFORMATION Name:______________________________________ Birth date:___________ Address: ____________________________________________________ Phone:_______________________ E-mail_______________________________ School Attending in Fall: _____________________ Gender: M F Requested Group Member:__________________ Grade Entering: 9 10 11 12 ***If you are entering 8th grade and have been on First STEP at least once– you have the option of attending STEP (10-day or 7-day) or First STEP!! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Please check which trip you would like to attend:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ HEALTH HISTORY Please give approximate dates Ear Infections ________ Chicken pox__________ Rheumatic fever______ Measles ___________ Convulsions _________ German measles ________ Diabetes____________ Mumps___________ Hay fever___________ Asthma________________ Operations or serious injuries (include dates) __________________________________________ Chronic or recurring illness__________________________________________________________ Other diseases___________________________________________________________________ Comments from parents/Guardians___________________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ IMMUNIZATION HISTORY State Law Requires Exact Dates DPT Series _________Booster_______ Tetanus Booster________ Typhoid____________ Polio OPV (Sabin) _____ Booster_______ Measles Vaccine (live) ______________ Tuberculin Test_____________________ German Measles (Rubella) ____________ Mumps Vaccine (live) _______________ Smallpox__________________________ Hepatitis B_________________________ Other_____________________________ Allergic to: Poison Ivy_______ Insect Stings______ Penicillin:________ BEE Stings_______ Foods?__________________________________________________________________________ Other___________________________________________________________________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ MEDICATION FORM NYS Health Regulations prohibit campers under 18 years of age from keeping either prescription or nonprescription (OTC) medications while at camp with the exception of emergency medications such as certain inhalers and epi-pens. ~All medication MUST be left with the leaders. ~All OTC medications must be in original containers with the original labels and labeled with the camper’s name. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ THIS SECTION BELOW MUST BE COMPLETED ~PRESCRIBED MEDICATIONS must be in the original pharmacy bottle with the camper’s name and dosage instructions. ~No OTC medications will be given unless the parent or guardian SUPPLIES the medication(s) and gives permission specifying the drug and instructions for use. I give permission for my child to take the following: Medication(s):____________ Dosage: ________ For:_________________ ____________Dosage: _________ For:_________________ ____________Dosage: _________ For:_________________ Parent/Legal Guardian’s Signature X_______________________________________ Date:_______________ Do you carry an epi-pen? YES NO Do you carry an inhaler? YES NO ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ This health record is correct so far as I know; the person described here has permission to engage in all program activities, except as noted. In the event I cannot be reached in an emergency, I hereby grant permission to the physician selected by the program director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child as named. I authorize the program director to assess any public school health records if deemed necessary. I grant permission for photographs of my child to be used in the promotion of the STEP program, unless otherwise noted. Parent/Guardian Name______________________________________________ Parent/Guardian Signature___________________________________________ Date__________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ To be read and signed by the participant: (by signing I agree that I read and agree to these terms) I understand I will be living in a tent during the duration of the program, I will be expected to share work duties such as cooking, cleaning and daily task chores. I will be asked to try challenging activities such as hiking, backpacking, rock climbing, and participating on the ropes course. I will be stretched physically as well as mentally and be expected to take part in team building activities. I realize I will be expected to set goals and abide by the community rules set up by the group. I realize that I am expected to finish the program. I will have fun! Participant Name_______________________________________________ Participant Signature X__________________________________ Date_________________ ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Complete & send the following items: 1. Application and health form 2. Rock waiver (for Ropes and Rocks trip only) 3. $15 non-refundable registration fee to reserve your spot Mail to: STEP Adventure, Wilderness Adventures Houghton College One Willard Ave Houghton, NY 14744 *More information regarding times will be sent to you upon receiving you application!! ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Additional Questions? Call: 585.567.9497 or Email: jaynie.nafziger@houghton.edu ~Call for information regarding making donations to Wilderness Adventures! We are always in need of certain items and your tax-exempt right-off monetary donations! ~Ask about volunteering to bake cookies for registration day!
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