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CAMPER APPLICATION -2014 CA M PER FAM ILY

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The Salvation Army PINE LAKE CAMP
CAMPER APPLICATION -2014
REGISTRATION DEADLINE at DHQ one week before start of camp.
Cancellation 7 days or more prior to camp: 50% refund.
Cancellation less than 7 days or no show: no refund
CAMPER
 I understand that without the completed application and health form my application WILL NOT be processed
First Name
Last Name
Age at Time of Camp
School Grade Completed (June 2014)
Home Phone Number:
Boy

Birthday
Day
Girl
Month

Year
R
Camp Session for which application is being made (please mark X in appropriate box)
Date
For Geographical location listed

Holiday 1
July 14-18
Deadline for Registration at DHQ is July 7 (Cranbrook, Drumheller, Medicine Hat,
Red Deer, High River & Lethbridge)

Holiday 2
July 21-25
Deadline for Registration at DHQ is July14 (Lloydminster, Peace River, St. Albert,
Wetaskiwin, & Edmonton)
$265
7 to 12

Holiday 3
July 28-Aug1
Deadline for Registration at DHQ is July 21 (Calgary Area)
$265
7 to 12

Teen
August 4-8
Deadline for Registration at DHQ is July 28 (all of Alberta & Northern Territories,
Cranbrook and Fernie )
$265
13 to 16
FAMILY
Camp
Cost
$265
Age
7 to 12
Parent or Guardian Name
Home Address
Home Phone #
City
Province
Postal Code
Cell Phone #
Parent/Guardian Email address
Work #
Social Worker
Agency phone #
Agency Name
Agency cell phone #
CAMP FEES
$265.00 -Holiday Camp
$265.00- Teen Camp
Camp Subsidies are available – please request information.
To be completed by Corps / Ministry Unit
Non-WRAC please fill in this section
Total:
Ministry Unit:
Officer Signature:
Western Regional Accounting Clients – complete this section to authorize payment from your account
Fund:
Department:
Date:
Approved by:
Ministry Unit:
Account:
Total:
CAMPER 2014 APPLICATION (Continued)
Please Print (Use separate application for each camper)
Information
Cabin Mate Request:
Name
Age
Gender
Cabin mate requests are only accommodated if your cabin mate is the same age/gender and you both requested one another.
Language
Please indicate your child’s first language, if other than English:
If your child’s first language is not English, please indicate their proficiency in English.
Good 
Poor 
Is there a custody issue related to the child?

No 
None
Yes 
CUSTODY & RELEASE NOTATION
If Yes, explain:
Will you permit other people to pick up your child from camp? Yes  No 
Please list people who have your permission to pick up your child from camp. Anyone picking up children will be required to show
ID.
Conditions of Enrollment
1.
The parents or guardians submitting this application, are
those having legal custody over the child. Conditions of
custody, if applicable, will be fully communicated in writing
to Pine Lake Camp, including a photocopy of the section of
any court order referring to visitation rights.
2.
The Camp Director reserves the right to dismiss a camper
without a refund who in their opinion, is a hazard to the
safety or the rights of others, or who appear to have
rejected the reasonable controls of the Camp.
3.
Every precaution is taken for the safety and good health of
the campers, but in the event of an accident or sickness I
hereby release Pine Lake Camp, its Directors, staff
members, employees, The Salvation Army, volunteers, and
support from all claims, demands, right of action, causes of
action, present or future, whether the same be know,
anticipated or unanticipated.
4.
5.
In the event that a guest requires prescribed medication at
Pine Lake Camp or requires special medication,
transportation, X-ray or treatment beyond that which is
possible at the Camp, the parents/guardian will be
immediately notified and will be responsible for any
additional expense.
6.
In the case of surgical emergency, I hereby give permission
to the physician selected by the Director to hospitalize,
secure proper treatment for and to order injection,
anesthesia or surgery for my child named on this
application.
7.
It is herby acknowledged that the undersigned leave the
said child with the said Camp at their own risk and the
said Camp shall not be liable for any damages arising from
any personal injuries sustained by the child in, on or about
the lands and premises of Pine Lake Camp or while
engaged in or attending any classes, exercise, activities.
Campers with a contagious disease cannot remain at camp.
Permission
Please initial the appropriate boxes:
I accept the conditions outlined as stated in the CONDITIONS OF ENROLLMENT above.
YES
NO
(initial box)
I give permission to Pine Lake Camp to use any photograph or video footage my child is in for promotional materials.
YES
NO
(initial box)
It is The Salvation Army’s intention to use your personal information to keep in touch with you throughout the year; and
to notify you of opportunities in children’s ministries available near your place of residence. May we contact you?
YES
NO
(initial box)
PRINTED NAME OF LEGAL GUARDIAN OR PARENT:
SIGNATURE OF LEGAL GUARDIAN OR PARENT:
The Salvation Army
PINE LAKE CAMP
Health & Medical Form - 2014
The Salvation Army Pine Lake Camp, 9618-101A Ave, Edmonton AB T5H 0C7
Phone: (780) 412-2730 Fax: (780) 425-9081
CAMPER
PLEASE NOTE: Before we can register your child, this form must be completed, signed and sent along with your
application form. Physician’s report is not required but may be sent in addition to this form, if available.
First Name
Last Name
Parent or Guardian Name
Age
Address
City
Emergency Contact
Male

Female
Prov

Postal Code
Please print clearly
Parent or Guardian Name
Home phone #
Work phone#
Cell phone #
Fax #
Email
Family Physician
Other Emergency Contact
Home phone #
Work phone #
Cell phone #
Fax #
Email
Physician’s Phone #
The Health History must be completed. For legal reasons this form needs to be filled out by the legal guardian or parent.
Incomplete forms will be returned and registration postponed until a completed form is submitted by the legal guardian.
Please indicate ALL ALLERGIES and give details or treatment – be specific
Allergies
Allergic to:
(please specify)
A) Medication:
B) Foods:
C) Insects:
D) Environmental
E) Other
Reaction
(please specify)
Severity
(mild, medium, severe)
Treatment/medication
required
If any allergies are severe:
A) does the camper carry an:  ana kit? Or  epipen?
B) does the camper know how to use an:  ana kit? Or  epipen?
Other than food allergies
Dietary Restriction
Medication
Condition
Immunizations
Please list ALL MEDICATION your child is taking / including Dosage and reason for medication:
Name of Medication
Dosage
When taken
Have the following immunizations been received? Please indicate dates.
Chicken Pox
Tetnus only
Tuberculin neg
DPT (Diptheria, Pertussis, Tetnus)
Hepatitus B
Tuberculin test-positive
Diptheria
Measles/Mumps/Rubella
(OR)TD (Tetanus & Diptheria)
Polio
Medical Profile
Please check the following that your child has experienced or is experiencing.
 Convulsions
 Fainting
 Lactose Intolerant
 Sleepwalking
 Diabetes
 Headaches
 Nose bleeds
 Surgery-recent
 Ear infections
 Homesick tendency
 Serious injury-recent  Surgery-recent
 Urinary tract infection - recent
Please attach a note giving details of the above if necessary and any additional information you feel the Camp Directors should know
or that will require attention. If your child has a medical condition, we will need a letter from your Doctor stating the applicant is
capable of attending. Attached Note:  Yes
 No
 Asthma
 Bed-wetting
 Contagious disease
Please Note that campers cannot come to Pine Lake Camp with contagious diseases, this includes head lice.
CAMPER PROFILE




We are interested in providing the best camp experience possible for your child. At Pine Lake, most
of the activities take place outdoors. To assist us, please check which characteristics would best
describe your child.
Shy with others his/her age
 Indifferent
 Makes friends easily
 Happy
Has difficulty keeping friends
 Nervous
 Easy going
 Well coordinated
Prefers passive activities
 Sensitive
 Tires easily
 Athletically inclined
Enjoys competitive sports
 Aggressive
 Emotional
 Shy with adults
To the best of my knowledge, my child is in good health. If my child is exposed to any INFECTIOUS DISEASE within FOUR (4)
weeks prior to leaving for Pine Lake Camp, I will notify the registration office.
I hereby give permission for my child to receive basic non-prescription remedies ( ie, Tylenol, cold medicine, Hydrogen Peroxide,
Head Lice treatment, etc.) if deemed necessary by the Camp First Aid Provider.
I hereby give permission for my child to be administered prescription drugs by the Camp Health Care Provider - as listed on the
medical form.
If my child has a medical emergency I give permission to have the Camp Director refer my child to hospital for treatment and to
transport my child to the medical facility. I also understand that the Camp Director will try to keep me informed of any emergency
plans by phoning me either at home, work or other emergency contact as noted under Emergency Contact information.
Date:
Signature of Legal Guardian/Parent:
FOR CAMP USE ONLY
Date:
Diagnosis
Treatment
Parents Notified?
Yes:  By Phone
Comments:
Parents not notified:
Nurse signature:
Camp Director signature:
Comments/Reason:
 By letter
Date:
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