2013 Summer Camp Registration
Ages 6-9 – Farm Crazy – June 13 Bovine Basics – June 17 Blueberry Blast – June 24
Ages 9-12 – Bovine Basics – July 20 Blueberry Blast – June 27
Cookin’ on the Farm – July 15 Cookin’ on the Farm – July 18
Ages 12-18 – Canning & Processing – Aug. 5-8 Apple Canning & Dehydrating – Sept. 2
First Name: _____________________________ Last Name: ___________________________________
Home Phone Number: (____)______________________ email: ________________________________
Birthdate:____________________ Age: _______ Rising Grade this fall: _____________
Parents/Guardian(s): _______________________________________Phone Number________________
PERMISSION AND AUTHORIZATION
I certify that the child registering is in good health and may participate in the camp activities for the
selected program. I authorize the officials of Christ the King Erdkinder Program and its affiliate, The
Heerschap Family Farm to act in an emergency and give permission to the physician selected physician
to hospitalize, secure proper treatment, and/or order injection, anesthesia, or surgery for the camper
named on this form. I will abide by the camp’s decision should it be necessary to send the camper home
for any reason, including illness and behavior. I give Christ the King Erdkinder Program and partner
organizations permission to use photos and video recording of the camper for publicity purposes. I will
participate fully in the camp program, and will accept the camp’s decision regarding area assignments.
_________________________________ ____________________ ______________________________
Signature of Parent/Guardian/Adult Date
My camper may be released to the following adults (including carpool drivers or those who may
pick up in an emergency.)______(Initials)
1. Name_________________________________ Relationship: _________________Ph:_____________
2. Name_________________________________ Relationship: __________________Ph:_____________
3. Other means of dismissal permitted (walking, bicycling, taxi, etc.):_____________________________
The parent/guardian may send a signed note to make changes to this list. People picking up campers must bring a photo ID. If a person not listed above arrives to pick up a camper, the camper will remain with camp staff until the parent/guardian has been contacted and has given permission for the release. If there are specific people to whom the camper may not be released, please inform the camp in writing.
Insurance Policy:_______________________________ Date Initiated:_____________________
Insurance Policy no.:____________________________ Name on card:___________________________
Allergies: □ No known allergies.
□ This camper is allergic to: □ Food □ Medicine □ the environment (hay fever, insects, etc.)
(Describe below the allergy and the reaction seen.)
We cannot guarantee that any area at camp is allergen-free
Diet and Nutrition: □ This camper eats a regular diet. □ This camper has special food needs.
General Health History: Check “Yes” or “No” for each statement. Explain “Yes” answers below. Has/does the camper:
1. Been hospitalized/had surgery in past 2 yrs? □ Yes □ No
2. Have recurrent/chronic illness(es)? □ Yes □ No
3. Had a recent injury/illness/infection? □ Yes □ No
4. Ever had a head injury or concussion? □ Yes □ No
5. Have asthma*/wheezing/shortness of breath? □ Yes □ No
6. Have diabetes? □ Yes □ No
7. Had seizures? □ Yes □ No
8. Have severe or frequent headaches? □ Yes □ No
9. Wear glasses/contacts/protective eyewear? □ Yes □ No
10. Had fainting or dizziness? □ Yes □ No
11. Have frequent bloody nose? □ Yes □ No
12. Have motion sickness? □ Yes □No
13. Have a phobia? (note type/severity below) □ Yes □ No
14. Passed out/had chest pain during exercise? □ Yes □ No
16. Ever had back/joint problems? □ Yes □ No
17. Ever been treated for Lyme Disease? □ Yes □ No
18. Ever been stung by a bee? □ Yes □ No
19. Have problems falling asleep/sleepwalking? □ Yes □ No
20. Have any skin problems? □ Yes □ No
21. Severe reaction to poison ivy/oak? □ Yes □ No
22. Have problems with diarrhea, constipation, □ Yes □ No
or frequent stomach aches? □ Yes □ No
23. Traveled outside the U.S. in the past year? □ Yes □ No
Explain “Yes” answers in the space below, noting the number of each question requiring a response.
Mental, Emotional, and Social Health History: Check “Yes” or “No” for each statement. Explain “Yes” answers below. Please note that we treat each camper with love and need to know which campers need a higher dose of this. You may call and discuss this information confidentially if you wish.
Has/does the camper:
1. Ever been diagnosed with attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)? □ Yes □ No
2. Ever treated for emotional/behavioral difficulties, self-harm, or an eating disorder? □Yes □ No
3. Ever have need for an aide at school? □ Yes □ No
4. Used an individualized education plan (IEP) during the previous school year? □ Yes □ No
5. Speak a primary language other than English? □ Yes □ No
Explain “Yes” answers in the space below, noting the number of each question requiring a response. Attach additional pages or contact the Camp Director to provide additional information if needed.
To better care for your camper: Note any additional information about the camper’s behavior
or physical, mental, emotional, and social health that you think important or that may affect
the camper’s ability to participate in the Camp program (shyness, learning style, etc.) List any
strategies used to manage the concern or enhance the camper’s experience.
Medications at home:
□ This camper does not take medications regularly at home.
□ This camper takes the following medications at home. (Describe medication and condition below.)
□ Daily: □ Seasonally: □ Other:
Note: All medications must have the child’s name clearly printed on the container at camp.
Medical Waiver and Authorization (agreement is required for participation):
Please initial the following:
_________Medical Release: This health history is correct and accurately reflects the known health
status of the named camper. The camper described has permission to participate in all camp activities
except as noted by me and/or an examining physician. I give permission to camp staff to provide routine
health care; to administer prescribed or over-the-counter medications as needed unless otherwise
noted; and to provide or obtain emergency care and transportation for the camper if needed. I give
permission to the physician selected by the camp to order x-rays, tests, and treatment related to the
health of my child both for routine health care and in emergency situations. If I cannot be reached in an
emergency, I give my permission to the physician to hospitalize, secure proper treatment for, and order
and administer medication, injection, anesthesia, X-rays, special procedures, or surgery for this child,
if deemed medically necessary. I understand that I am responsible for the cost of any medical care or
prescriptions my child requires. I agree to the release of any records necessary for treatment, referral,
billing, or insurance purposes. I understand that information on this form will be shared on a “need to
know” basis with camp staff.
________Medications: I authorize Christ the King Erdkinder Program’s adult staff to administer as listed
above Medications At Camp and Asthma or Allergy Emergency Medications, as directed, to my child
for whom it was prescribed. I understand that all medications at camp must be checked by the camp’s
health supervisor, and each dose monitored by a camp staff member. I understand that all medications
must be in their original containers, unexpired, and labeled with specific instructions, including the
child’s name and dosage, and that any prescription medications must include the full pharmacy label.
________Insurance: I certify that the named camper is covered by health and accident insurance or Medicaid and that the policy information given is correct.
_________Program: I give permission for my child to participate in all day camp activities similar to
those described in the camp brochure, or website. I understand that Christ the King Erddkinder Program
reserves the right to change program activities or instructors and cancel programs, in its sole judgment if
it is necessary and appropriate to do so.
_________Expectations/Dismissal: I have informed the Camp Director and other appropriate staff of
any limitations to my child’s participation and agree to abide by Christ the King Erdkinder Program’s
sole judgment as to whether my child can be accommodated in the camp program. I understand that
failing to disclose any physical, emotional, or behavioral needs or conditions may result in the child’s
dismissal from the program without refund. I understand that my child must follow the stated behavior
expectations and farm safety rules and that Christ the King Erdkinder Program reserves the right in its
sole judgment to dismiss without refund any child whose behavior interferes with the rights and safety
of others or consistently disrupts group dynamics or activities.
________Sun and Bugs: I understand that outdoor exploration is an integral part of Farm Camp
programs and my child will be exposed to risks including but not limited to sun, ticks, and insects. I
understand that it is my responsibility to apply sunscreen and insect repellant to my child before
bringing him/her to camp each day. I give permission to Farm Camp staff to assist my child in reapplying
sunscreen, insect repellant, and topical anti-itch cream. I understand that some ticks may transmit
disease after being attached for over 24 hours, and it is my responsibility to check my child’s body
thoroughly at the end of the day and to remove any ticks that may become attached. I am responsible to
do a complete check upon my child’s return home.
________Payment, Cancellation, and Refund: Payment is due upon registration and cancellation due
to unforeseen circumstances such as staff health issues, severe weather, or other disruption will result
in the option of rescheduling the camp date or a 50% refund.
________Day Camp Audio/Visual Image Release. Christ the King Erdkinder Program uses images
and sounds of children and staff participating in programs as a way of documenting the enjoyable and
educational experiences they have while exploring the natural world on their webpage. Christ the King
Erdkinder Program will not identify my child, or will identify my child only by first name and program,
unless I give specific written permission to do otherwise.
In consideration of the above, I hereby consent to (1) photographing, filming, and video-taping my child,
and (2) using and displaying images and sounds of my child on websites, archives, and promotional
or information material, including but not limited to newsletters, brochures, advertisements, and
newspaper articles, and I hereby waive and release on behalf of my child any rights of compensation for,
or ownership of, such images and/or sounds of my child.
I have read this media release and agree to its terms and conditions. Christ the King Erdkinder Program director and students make every effort to conduct safe programs, to orient and support children, and to inform families of inherent risks. Some activities may involve risks that children do not routinely encounter at home. Risk management is an essential element of all the activities offered. While we anticipate that these efforts will ensure the wellbeing of each child, we are also aware that it is neither possible to foresee every contingency nor to eliminate all risk.
I understand that program activities may include, but are not limited to: hiking on uneven terrain,
playing active games, participating in activities near water, and other activities such as food preparation
& cooking, making cheese, and being near program animals. The camp selected may include using knives
or other hand tools, operating machinery such as an electric mixer or grain grinder, cooking on a gas
stove, swimming, hiking, and participating in an obstacle course that may include both high and low
elements. Other risks may be inherent in program activities. I acknowledge that such risks exist, and I
hereby agree on behalf of my child to assume such risks. Further, on behalf of my child, I hereby release
and forever discharge, and agree not to sue, and agree to indemnify and hold harmless Christ the King
Erdkinder Program or its affiliate, The Heerschap Family Farm, and its officers, directors, employees,
and volunteers and each of them, from and against any and all liabilities and obligations of every kind
and description, which I shall or may have against them or any one or more of them arising out of, or
in connection with, my child’s participation in the Summer Camp program and activities, including, but
not limited to, for any personal injury that my child may suffer while participating in the Summer Camp
program and activities, excepting in the case of gross negligence. I understand and agree on behalf of
my child that my child shares the responsibility for safety during the Christ the King Erdkinder Programs
and activities, and I personally assume on behalf of my child that responsibility. I understand and
certify that my child’s participation in the Summer Farm Camp program and its activities is completely
voluntary, and that I have become familiar with the program activities in which my child may participate
as described in the brochure or on the website.
Signature of Custodial Parent/Guardian: _______________________________ Date: _______________
Print Name: ________________________________Relationship to camper: _______________________
Notes, questions, comments: