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Kenosha and Racine County Day Camps Summer 2014 Outdoor coo king

Sports field

Arts

Games

Nature stud y

Outdoor skil ls

Campfires

Te a m b u i l d i n g

Crafts

Kenosha & Racine County Day Camps Offer: • Volunteer-led day camp for grades K-12 in your community • Trained & experienced adult directors • Beautiful natural settings • Scenic nature trails • Fun and enriching experiences

This year’s camp theme:

Changing the world – Superhero Style

Kenosha & Racine County Day Camps Trefoil Oaks Program Center | Racine July 14-18 • July 28-August 1 Camp Pottawatomie Hills | East Troy August 4-8 Woodhaven Program Center | Kenosha August 4-8

Changing the World:

Superhero Style

Discover your many strengths and find new ways to use them. Welcome to Girl Scout Day Camps in Kenosha and Racine Counties! See why camp is where we are Changing the World: Superhero Style. The volunteer led day camps serving girls in Kenosha and Racine counties are offered at three different locations. All three camp properties feature beautifull forests, play fields and nature trails, giving girls lots of room to explore, while indoor facilities provide all the comforts of home. Trefoil Oaks Program Center includes an air conditioned lodge, archery range and sports field. Woodhaven Program Center is nestled in town with a butterfly garden, a forest for shade and air conditioned activity rooms. Camp Pottawatomie Hills has an archery range, sports field and swimming, canoeing and paddle boating under the watchful eye of trained and certified lifeguards on crystal clear Pleasant Lake.

A Typical Day at Camp 9:00 a.m. Campers arrive and opening flag ceremony 9:15 a.m. Arts and crafts, nature, water activities, theme activities, lunch and more fun 3:45 p.m. Songs, closing flag ceremony 4:00 p.m. Campers depart

Tre fo il O a ks P ro g ra m C e n te r

With positive role models, new friends and exciting camp fun, day camp will create memories to last a lifetime. We look forward to seeing you and your girl at camp this summer.

Adult volunteers - vital to our success Volunteer-led day camp cannot happen without adults like you! Volunteering one, two, or more days gives you the unique opportunity to spend time with your camper while ensuring that we meet our safety standards. If you cannot volunteer during the week of camp, please offer to help with pre-camp preparations or camp set-up or take-down. In most troops, parents share the adult volunteer responsibilities. Our volunteers tell us that their favorite part about being at camp is spending time with their camper, getting to know her friends and seeing her build new skills and have fun.

“I had a great time. I am new to Girl Scouts and feel I learned a lot at camp, especially from my CIT (Counselor in Training) and PA (Program Aide), and even some from the troop. The camp volunteer team made me feel comfortable and answered all my concerns and questions. They were easy to talk to. I can’t wait to come back next year.” – Olivia, Brownie mom and first-time day camp volunteer

Adults needed • Each day one adult is needed for every five girls. • Specific roles: five-day volunteers, unit volunteers, bus captains, overnight chaperones, activity station volunteers (crafts, outdoor skills, games, nature, kitchen), archery instructors (training provided), camp set-up (Sunday) and takedown (Friday)

Fees: • Camper (entering grades 1-7): Fee includes day camp T-shirt, patch, busing and some meals/ snacks. • PA/CIT (entering grades 8-12): No fee. Includes day camp patch, busing and some meals/ snacks. Girls pay overnight fee, if applicable. • Overnights See each camps information for age requirements and availability.

Up, Up & Away Super Girl Day Camp

Registration Dates

Trefoil Oaks Program Center July 14-18 | 9:00 a.m. - 4:00 p.m.

• $100 per camper on/or before June 1 • $125 per camper June 2 - July 6 • Registration closes July 6

Sponsored by Trefoil Service Area

Overnight Information

Camp Director: Sharon “Pepsi” Roeschen, Volunteer pepsiroeschen@yahoo.com | 262-634-8047 (h)

Find your supergirl power at day camp. Leap tall buildings? Maybe not, but challenge yourself to reach the top of the rockwall. Aquaman has nothing over all the fun you will have swimming and boating for a day. Amaze your friends with your ability to start a fire without a match. Nature, games and crafts allow your creativity to soar. Recharge your superpowers with tasty s’mores, snow cones and the delectable delights you create over a fire. Thursday, is an all-camp field trip to the beach at Camp Alice Chester for swimming and boating.

• Overnight: $35/night • Girls entering grades 4-12, Wednesday, July 16. • We will spend the evening at the horse ranch. Dinner at the ranch, horseback riding, crafts, games, snacks, bus and breakfast are included in the fee. • Bed space at Trefoil Oaks Program Center is limited and this is a girl activity; bunks are assigned based on date of registration (an inflatable mattress can be used if bunks are filled). • Adults going horseback riding pay $35.

Bus Transportation • Bus transportation is not available. • Campers and volunteers arrive and depart Trefoil Oaks Program Center.

Save the dates Adult Volunteer and CIT Orientation Monday, July 7, 6:00-8:30 p.m., Trefoil Oaks Program Center

Mission: Superhero day camp Trefoil Oaks Program Center July 28-August 1 | 9:00 a.m. - 4:00 p.m. Sponsored by Windy Waters Service Area

Camp Directors: Abra “Moon” Dexter, Volunteer Kdexter1@wi.rr.com | 262-534-3501 (h) Jennifer “Toots” Ebert, Volunteer bugnsamsmom@aol.com

You have been selected to join an elite team of Superheros! Your mission is to help save the planet from the nasty members of P.E.S.T. You will be challenged, encouraged, educated and energized each and every day of your five day mission. Together with the Day Camp Team you will uncover hidden talents, develop important skills, create amazing things, learn new things and find friends everywhere you look. Directors Moon and Toots hope that with your help we can save the day, the week and possibly the planet. Don’t let P.E.S.T. win…join us!

PA Orientation Check the webpage for information.

Registration Dates • $100 per camper on/or before June 29 • $125 per camper June 30 - July 13 • Registration closes July 13

Overnight Information • Overnight: $15/night • Girls entering grades 4-12: Thursday, July 31. • Bed space at Trefoil Oaks Program Center is limited and this is a girl activity; bunks are assigned based on date of registration (an inflatable mattress can be used if bunks are filled). • Girls entering grades 8-12: (PAs/CITs) Sunday, July 27, 1:00 p.m. arrival.

Bus Transportation We reserve the right to cancel or change a bus stop if there are not enough bus riders. You will be notified at least two weeks prior to camp if a bus stop you registered for is canceled. Bus Stops • Burlington

• Union Grove

Save the dates Adult Volunteer and PA Orientation Sunday, July 27, 2:00 p.m., Trefoil Oaks Program Center

Adult Day Camp Skills Training See website for date, Trefoil Oaks Program Center

• Waterford

Superhero Training Day Camp

Registration Dates

Camp Pottawatomie Hills August 4-8 | 9:00 a.m. - 4:00 p.m.

• $100 per camper on/or before June 1 • $125 per camper June 2 - July 21 • Registration closes July 21

Sponsored by Country Cousins Service Area

Overnight Information

Camp Directors: Crissy “Crusty” Busch, Volunteer CountryCousins504@yahoo.com 262-864-4291 (H) | 262-880-9932 (C) Kate “Crabcakes” Sieg, Volunteer groverunner@mac.com | 262-930-4994

• Overnight: $15/night • Girls entering grades 5-12, Wednesday • Girls entering grades 8-12 (PAs/CITs): Sunday (1:00 p.m. arrival), Wednesday, Thursday

Bus Transportation Put the ‘Super’ in day camp when you prepare to be a superhero. Dream of what superhero you will be as you try out the different powers and skills to change the world. Meet a paramedic who has saved lives. Help a science teacher launch a rocket. Explore your superhero skills with swimming, boating, dancing, art, music, stories, songs and games. Enjoy superhero training camp as we celebrate Ca mp Po tta wa tom the last day of camp. Enjoy all your ie Hil ls favorites—swimming, canoeing, archery, snow cones, cooking and crafts during this fun, exciting week. If you are ready to be inspired to have fun…this is the camp for you.

We reserve the right to cancel or change a bus stop if there are not enough bus riders. You will be notified at least two weeks prior to camp if a bus stop you registered for is canceled. Bus Stops • Burlington • Kenosha County Center • Racine • UGES Union Grove • Waterford • Yorkville School

We are a PEANUT FREE camp!

Calling all Supergirls Day Camp

Registration Dates

Woodhaven Program Center August 4-8 | 9:00 a.m. - 4:00 p.m.

• $100 per camper on/or before June 1 • $125 per camper June 2 - July 21 • Registration closes July 21

Sponsored by Kenosha Service Areas

Camp Directors: Lisa “Luna” Droessler, Volunteer ldroessler@gmail.com | 262-694-8739 Jennifer “Blondie” Lawler, Volunteer jenniferklawler@hotmail.com | 262-948-0574

Get ready for an adventure of heroic proportions while learning to be a superhero. Woodhaven’s girl heroes will explore a variety of super powers: get strong and mighty on the sports field, build super-smarts exploring science experiments, and get super-creative designing super-logos, masks, and more. Girls will also make their own super-snacks to keep themselves healthy and strong. Join Wo od ha ve n Pr og us at Woodhaven to meet new Girl Scout ram Ce nte r friends and have an action-packed, fun-filled week.

Overnight Information • Overnight: $15/night • Girls entering grades 4-12, Wednesday, August 6

Bus Transportation We reserve the right to cancel or change a bus stop if there are not enough bus riders. You will be notified at least two weeks prior to camp if a bus stop you registered for is canceled. Bus Stops • Christ Lutheran Church, Salem • Nash Elementary, Kenosha • Pershing Plaza, Kenosha

How to register Registration will automatically open Monday, February 3, at 11:00 p.m. Online registrations are processed first and then paper registrations. • Girls registering with an adult volunteer will guarantee registration. • Registration may close early if girl registrations begin to exceed adult volunteer coverage. • Adults volunteering complete the adult day camp registration, online

application, and background check. Adults volunteering at day camp are also asked to become a registered member of the organization. ed • Program Activity Credits (PAC) earned m through the Girl Scout Cookie Program Activity or Fall Nut Sale can reduce the cost for the girl who earned the PAC to attend camp. Write the camp name on the PAC and mail in if registering online or attach to paper registration form.

Secure Be a Superhero! your spo Te e n l e a d e r s h i p T ta opportunities camp an t d Close to 1,000 teens register online spend part of their today! summer leading

Online • Go to www.gswise.org and click on Camps. Click on Volunteer-Led Day Camp and then Register for Camp. • Create one account per family so that camper’s parent/guardian receives confirmation information. • Pay full payment with a credit/debit card (Visa or MasterCard) or checking account.

Paper • Complete the Registration and Health History forms. • Pay full payment with a credit/debit card (Visa or MasterCard) or checking account.

Refunds/cancelations • Refunds, minus $25 nonrefundable processing fee, are available for cancelations received six weeks prior to the session start date. Within six weeks, refunds, minus $25, will only be issued for medical reasons, summer school, a death or critical illness in the immediate family or if the family moves out of the area. • Cancelations must be made in writing.

Financial assistance • Financial assistance is available for registered members of Girl Scouts of Wisconsin Southeast to help families meet the cost of sending their girl to camp and events. Financial assistance is funded by gifts to Girl Scouting and proceeds from the Girl Scout Cookie Program Activity. • A financial assistance form can be found at www.gswise.org under Forms and Resources. If registering online, mail completed form to the address listed within one week or mail with paper registration and $25 nonrefundable deposit. • One resident camp, one day camp, and one event will be considered for financial assistance per girl

activities at day camp, a becom becoming real-life superheroes to younger Girl Scouts. Over 90% of teens agreed that “at Girl Scout camp, my experiences have helped prepare me to be a better leader.”

Program Aide-in-Training (PAIT) Entering grade 7

Build your leadership skills as you learn how to be an outstanding Program Aide. In addition to participating in camp activities with other PAITs, you get to show your leadership skills as you help and lead younger campers. PAITs pay the camper fee.

Program Aide (PA) Entering grades 8-9

As a Program Aide, you will continue to mentor younger campers and help adults with activities and/or in a unit. Check the website for required PA training dates and your day camp’s webpage at www.girlscoutdaycamp.com for required camp training dates. There is no fee to be a PA. (PAs pay the overnight fee, if applicable.)

Counselor-in-Training I and II (CIT I and II) Entering grade 10 - graduating seniors

Be a CIT... your next leadership step. CITs lead activities or a unit with an adult mentor. CIT training and camp training are required. See www.girlscoutsdaycamp.com for dates. There is no fee to be a CIT. (CITs pay the overnight fee, if applicable.)

Girls with additional needs Let us know of any concerns you may have. Our goal is to provide a positive camp experience for all girls. Providing us with information about medications, special diets and nighttime routines along with physical and mental limitations will help us provide a positive camp experience for your girl. For specific questions or situations please email or call the volunteer day camp director.

Confirmations Confirmations will be sent by your volunteer day camp director two weeks prior to your camp session. Packing list, information about specialty or theme days, and more are listed on your day camp’s webpage at www.girlscoutsdaycamp.com. Confirmations include: • Pick-up cards and procedures • Unit assignment and bus stop information (if taking the bus) • Address and directions to camp

All girls welcome All girls are welcome to attend day camp. If your girl is not a registered Girl Scout, include an additional $15 for membership dues with payment.

For more information on day camp go to www.girlscoutdaycamp.com 800-565-4475

Girl Scouts of Wisconsin Southeast

Volunteer Led Day Camp Adult Registration

COMPLETE AND MAIL TO:

Girl Scouts of Wisconsin Southeast P.O. Box 14999 Milwaukee, WI 53214-0999

Only completed forms will be accepted. To be filled out by an adult.

Adult volunteer’s name: _________________________________________________________________________ Camp Name: ___________________________________________________________ Address: _________________________________________________________________________ City/State/Zip: _____________________________________________________________ Email Address: _______________________________________________ Home Phone: (_________)___________________________ Cell: (_________)___________________________ Birthdate: ____________________________________________ Occupation: _________________________________________________________________________________________ Are you a registered Adult Girl Scout for 2013-2014? ❒ Yes ❒ No If no, you can enclose the $15 GSUSA membership dues and support Girl Scouting by becoming a member. BACKGROUND CHECK AND REFERENCES (REQUIRED) ❒ Prior to submitting this form I have completed an online application and background check and submitted references at www.gswise.org. ❒ I have already completed an online application and background check with the Girl Scouts Wisconsin Southeast within the last 3 years. MEDICAL HISTORY Name of family physician: __________________________________________________________ Phone number: (_____________)_________________________________________ ALLERGIES ❒ Animals ❒ Hay Fever ❒ Insect Stings ❒ Plant ❒ Pollen ❒ Medicine/Drugs ❒ Food ❒ Nuts ❒ Milk ❒ Latex ❒ Other Type and severity of reaction: _____________________________________________________________________________________________________________________________________ ILLNESSES ❒ Bleeding/Clotting Disorders ❒ Seizures ❒ Asthma ❒ Diabetes ❒ Heart Defect/Disease ❒ Musculoskeletal Disorder ❒ Other If other, list special needs: ________________________________________________________________________________________________________________________________________ SPECIAL NEEDS ❒ Wears Contacts/Glasses ❒ ADHD or ADD ❒ Hearing Defect/Disease ❒ Hypertension ❒ Other: ________________________________________________________________ IMMUNIZATIONS ❒ Tetnus DPT: _________________________________ ❒ HepB: _________________________________ (optional) MEDICATIONS ❒ Yes ❒ No If yes, does this need to be administered at camp? ❒ Yes ❒ No If yes, please explain: _____ ________________________________________________________________________________________________________________________________________ Do you have any restrictions or special needs to physical activity? ❒ Yes ❒ No If yes, please explain: __________________________________________________________________ Do you require a special diet or have any dietary restrictions? ❒ Yes ❒ No If yes, please explain: ______________________________________________________________________ CAMP SPECIFICS Name(s) and troop number(s) of camper(s) attending camp: _______________________________________________________________________________________________________ Name(s) of Pee Wee(s) and/or boys(s) attending camp: _______________________________________________________________________________ ❒ M ❒ T ❒ W ❒ Th ❒ F I am Volunteering for: Day(s) ❒ S ❒ M ❒ T ❒ W ❒ Th ❒ F ❒ unknown

Nights

❒ S ❒ M ❒ T ❒ W ❒ Th

Transportation: Bus Stop ______________________________________ Ride Bus to Camp: ❒ M ❒ T ❒ W ❒ Th ❒ F Private Transportation: To Camp: ❒ M ❒ T ❒ W ❒ Th ❒ F

From Camp:

From Camp:

❒ M ❒ T ❒ W ❒ Th ❒ F

❒ M ❒ T ❒ W ❒ Th ❒ F

EMERGENCY CONTACTS Name: ___________________________________________________________________________ Relationship: ________________________________________________________________ Phone during camp hours: (_________)______________________________________________ Phone #2: (_________)_________________________________________________________ Name: ___________________________________________________________________________ Relationship: ________________________________________________________________ Phone during camp hours: (_________)______________________________________________ Phone #2: (_________)_________________________________________________________ Have you ever volunteered at day camp? ❒ Yes ❒ No If so, when and in what capacity? ____________________________________________________________________________ AREAS OF INTEREST - please check all that apply (directors will assign on the basis of need, not just interest) ❒ With my daughter ❒ Not with my daughter ❒ Boys unit ❒ Peewee unit ❒ Kitchen ❒ Bus monitor ❒ Shopper ❒ Crafts ❒ Nature ❒ Equipment ❒ Pre-camp preparation ❒ Set up (day before camp) ❒ Clean up (last day of camp) ❒ Other: _____________________________________________________________________ CAMP FEES ❒ $15 Girl Scout Membership for 2013-2014 (recommended) ❒ $10 Camp T-shirt Size: ❒ AS ❒ AM ❒ AL ❒ AXL ❒ AXXL ❒ AXXXL ❒ I would like a free camp patch ❒ $ ___________ Donation (accept my tax deductible gift to support camp) (❒ For Trefoil only -adult horseback riding $35 ________) ❒ Total enclosed: $ _____________ I have read the camp information and agree that I will abide by the regulations and procedures stated therein, including those on refund, non refundable deposit, and health. I understand that I am responsible for getting to and from this camp or bus stop. I give permission for photography/video of me to be taken for GSUSA, GSWISE, and the American Camp Association publicity and marketing purposes. If I am not already a registered Girl Scout, I give permission to register as a member of the Girl Scouts of the USA. I give permission to receive necessary health care and emergency medical treatment. The health history on this form is complete and accurate. I will not attend if I become exposed to any contagious disease, or if for any reason, I do not consider myself to be in good physical condition. Upon arrival the camp health personnel have the right to refuse to admit anyone to the camp who does not meet the acceptable health conditions e.g. temperature, contagious disease, etc.

Adult volunteer signature: ________________________________________________________________________________________________ Date: __________________________________

Girl Scouts of Wisconsin Southeast

COMPLETE AND MAIL TO:

Volunteer Led Day Camp Registration

Girl Scouts of Wisconsin Southeast P.O. Box 14999 Milwaukee, WI 53214-0999

Register only one person per form. See camp information for specifics. Visit www.gswise.org for additional forms. Please check every category Camper’s name: __________________________________________________________________________________________________________________________________________________ Address: __________________________________________________________________________________________ City: ____________________________________________________ County: __________________________________________________________________________________________ State:_________________ Zip: _____________________________ Phone: (________)______________________ Birthdate: _________________________________________________________ Troop # (if applicable): ________________ Grade in Fall 2014: __________ Troop Leader Name: _______________________________________________________________________________ School: _________________________________________________ Note: Confirmation information will be sent to your email address listed below. Please print clearly. Email address for confirmation: _______________________________________________________________________________________________________________________________________ Buddy Request (Name) (Check day camp web page for availability.): __________________________________________________________________________________________________ 1. Check Participation (grade in fall)

❒ Camper (grades 1-6) ❒ PAIT (grade 7) ❒ PA (grades 8-9) ❒ CIT (grades 10-12)

❒ Peewee ❒ M ❒ T ❒ W ❒ Th ❒ F ❒ Boy ❒ M ❒ T ❒ W ❒ Th ❒ F

2. Choose Day Camp(s) KENOSHA AND RACINE CAMPS ❒ Trefoil/ Up, Up, & Away Super Girl Day Camp • July 14-18 ❒ Windy Waters/Mission: Superhero Day Camp • July 28-Aug 1 ❒ Country Cousins/Superhero Training Day Camp • Aug 4-8 ❒ Kenosha/ Calling All Supergirls Day Camp • Aug 4-8 WASHINGTON AND WAUKESHA COUNTY CAMPS ❒ Lakeland • June 9-13 ❒ Deer Trails • June 16-20 ❒ Rising Stars/Meadow Springs • June 16-20 ❒ Prairie Hill • June 23-27 ❒ Sunny Trails • July 7-11 ❒ Enchanted Waters • July 14-18 ❒ Whispering Willows • July 14-18 ❒ River Valley • July 21-25 ❒ Sun Lakes • July 21-25 ❒ Alpha Moraine • July 28-Aug 1 ❒ Glacier Hills • July 28-Aug 1 ❒ Woodland Trails • July 28-Aug 1 ❒ Arrowhead • Aug 4-8 ❒ Indian Springs • Aug 11-15 ❒ Northern Lights • Aug 11-15

3. Choose Overnights (if applicable)

❒S ❒M ❒T ❒W ❒ TH

4. Choose Transportation List Bus Stop: _________________

5. Choose FREE Camper T-shirt (Girls entering grades 1-7 only) Select One YM (10-12) YL (14-16) AS AM AL AXL AXXL AXXXL

YM YL AS AM AL AXL AXXL AXXXL Progression Patch Adult Rain Poncho Youth Rain Poncho Bandana

7. Race/Ethnicity (optional, check all that apply)

Ethnicity ❒ Hispanic or Latino ❒ Not Hispanic or Latino

Camper fee: Overnight fee (if applicable): Trading Post fees: Donation amount:

$ _____________ $ _____________ $ _____________ $ _____________

Accept my tax-deductible gift to support camp.

GSUSA Membership Dues ($15):

$ _____________

(If not currently registered)

Program Activity Credit (attach) PAC #____: FINAL TOTAL:

– $ _____________ $ _____________

❒ Financial Assistance requested - a completed Financial Assistance form, found at www.gswise.org, and must be received with camp registration form.

Ride Bus From

QTY

$ 10.00 10.00 10.00 10.00 10.00 10.00 12.00 12.00 2.25 3.25 3.25 4.00

8. Camp Fees

Race ❒ American Indian or Alaskan Native ❒ Hawaiian or Pacific Islander ❒ White (Caucasian) ❒ African American or Black ❒ Asian

To

6. Advanced Trading Post (optional) Additional T-shirt Price

Private To

From

S M T W TH F

I have read the camp information and agree that my camper and I will abide by the regulations and procedures stated therein, including those on refund, nonrefundable deposit, and health of camper. I understand that I am responsible for getting my camper to and from this camp or bus stop. I give my camper permission to ride the bus, if applicable. I give my camper permission to attend and participate in all phases of this session (except those noted on the Health History form), including off-site trips, if applicable. I give permission for photographs/video of my camper to be taken for GSUSA, GSWISE, and American Camp Association publicity and marketing purposes. If my camper is not already a registered Girl Scout, I give my permission for them to register as a member of the Girl Scouts of the USA.

Parent/guardian signature: __________________________________________ Date: _________________

Enclose full amount which already includes the $25 nonrefundable deposit or enclose a minimum of $25 if applying for financial assistance. Outstanding balances, including gift certificates and Program Activity Credits are due May 12. If you register online or pay by credit/debit card, outstanding balances will be automatically charged no later than May 15. Pay in full if registration is received after May 12. Any additional fees or outstanding balances will be automatically charged 7-10 days prior to camp. For all credit/debit card or check/e-check transactions, bank/credit card statements will show payments processed by Active Network. Check enclosed payable to GSWISE Charge ❒ Visa ❒ MasterCard Account # Card holder’s name (print)

Signature

OVER FOR MANDATORY HEALTH HISTORY FORM

$ Exp. date

COMPLETE AND MAIL TO:

Girl Scouts of Wisconsin Southeast

Girl Scouts of Wisconsin Southeast P.O. Box 14999 Milwaukee, WI 53214-0999

Health History

For Office Use Date: ____________________

Please print clearly and use blue or black ink.

Entered: ________________

Camper’s name: ____________________________________________________________________________________________________________________________________________ Session #1: _______________________________________________________________________________________________ Date of session: _________________________________ Session #2: _______________________________________________________________________________________________ Date of session: _________________________________ Session #3: _______________________________________________________________________________________________ Date of session: _________________________________ Mother/guardian name: ________________________________ Phone during camp hours: (__________)____________________ Phone #2: (__________)________________________ Father/guardian name: _________________________________ Phone during camp hours: (__________)____________________ Phone #2: (__________)________________________ Camper is in custodial care of (check one): ❒ Both ❒ Mother ❒ Father ❒ Other _________________________________________________________________________________ Person(s) authorized to pick up child at camp/bus stop: ___________________________________________________________________________________________________________ Emergency Contacts (besides parent/guardian) 1. Name: ______________________________________________________________________________ Relationship: _______________________________________________________ Phone during camp hours: (_____________)____________________________________________ Phone #2: (_____________)________________________________________________ 2. Name: ______________________________________________________________________________ Relationship: _______________________________________________________ Phone during camp hours: (_____________)____________________________________________ Phone #2: (_____________)________________________________________________ Medical History Family physician name:______________________________________________________________________________________ Phone #: (____________)___________________________ Are any medications taken on a regular basis? ❒ Yes ❒ No

If yes, does this need to be administered at camp? ❒ Yes ❒ No

If yes, explain: _______________________________________________________________________________________________________________________________________________ Do you have any restrictions or special needs related to physical activity? ❒ Yes ❒ No If yes, explain: ______________________________________________________________ ____________________________________________________________________________________________________________________________________________________________

The following non-prescription medications are commonly stocked in the camp health center and used on an as needed basis to manage illness and injury. Cross out any of the following items the camper should NOT be given. • Antibiotic ointment (Neosporin) • Anti-itch cream or lotion • Athletes foot ointment or powder • Aloe or burn gel

• Tums • Ibuprofen (Advil, Motrin) • Acetaminophen (Tylenol) • Benadryl

Immunization Dates (M/D/Y) (Series Completed, Year of Booster) “Current” is not acceptable.

• Eye drops • Rubbing alcohol • Hydrogen peroxide • Laxative

• Anti-diarrheal • Epi Pen

CHECK ALL THAT APPLY Illness

Allergies – include severity

Others or Special Needs

❒ Heart defect/disease

❒ Animals ____________________________

❒ Wears contacts/glasses

❒ Musculoskeletal disorders

❒ Insect stings ________________________

❒ Fainting

❒ Asthma

❒ Pollen ______________________________

❒ Ear problems/tubes

❒ Bleeding/Clotting disorder

❒ Latex ______________________________

❒ Hearing impairment

❒ Seizures

❒ Medicine/Drugs _____________________

❒ Emotional behaviors

❒ Diabetes

❒ Nuts _______________________________

❒ Other ____________________

❒ Milk ________________________________

❒ ADD/ADHD (circle one) ❒ medicated not medicated

❒ Exposed to a contagious disease

____________________________

❒ Food (specify) ______________________

❒ Sleep disturbances

❒ Had a surgical operation

____________________________

❒ Other (specify) _____________________

❒ Menstrual cramps

❒ Had a serious illness

____________________________

Type & Severity of Reaction __________

❒ Nosebleeds

____________________________

______________________________________

❒ Other ________________________

____________________________

______________________________________

________________________________

Tetanus or DPT _____________________________ Polio _______________________________________ MMR _______________________________________ Hepatitis B _________________________________ Varicella/HIB ________________________________

Since last health exam:

Describe: ___________________________________

Please explain any items that you check. Include any useful information relative to any of these health conditions. ____________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________

I give my permission for my camper to receive necessary health care, prescribed medications, and emergency medical treatment. This health history is complete and accurate. I will not allow my camper to attend if they become exposed to any contagious disease, or if for any reason, I do not consider them to be in good physical condition. Upon arrival the camp health personnel have the right to refuse to admit anyone to the camp who does not meet the acceptable health conditions, e.g. temperature, contagious disease, etc. Parent/guardian signature: ______________________________________________________________________________________ Date: ______________________________________


2014 Racine and Kenosha Day Camp