ASYMCA Camp Rockfish Application Documents

Camp Rockfish Application

Summer 2012

Mail to: 226 Camp Rockfish Rd, Parkton, NC 28371 Attn: Resident Camp Registration

Phone # (910) 425-3529 Fax # (910) 875- 6177 Website: www.camprockfish.org

Campers Name________________________________ Preferred Name_________________ Male__ Female__

Birthday (M/D/Y)_________________ Grade entering ___________ Age during camp_______________

Child’s Mailing Address________________________________City____________________State____ Zip _______

Child’s Physical Address_______________________________City____________________State____ Zip ______

(if different from above)

E-Mail for updated Rockfish information ________________________________________________________

Please Indicate with whom camper lives: __Both Parents __Mother __Father __Guardian

Parents are: __Married __Separated __Divorced __Single __Re-married __Widowed

Emergency Contact (in case we cannot get in touch with parents/guardians)

1. ________________________ Relationship to camper __________________ Daytime Phone #(___)______________

Address __________________________City _______________State _____Zip_______Work # (___)______________

2._________________________ Relationship to camper __________________ Daytime Phone #(___)______________

Address __________________________City _______________State _____Zip_______Work # (___)______________

Insurance Carrier:_____________________________________ Subscriber: _________________________________

Subscriber Number: _________________________________

Sheltermate Request _______________________________________________

Have you been to Camp Rockfish before __Yes __No If yes, what years?________________

How did you hear about Camp Rockfish? __Internet __Camp Fair __Friend __Former Camper/Staff

__ Print __Ad __Sibling __Attended __Other______________________

With registration by mail, we encourage a check payment. However, if needed a credit card

payment can be made once forms are received. A Rockfish staff member will contact you for

credit card information to complete the registration process.

If you have any questions, our office can be contacted by phone at (910)425-3529 or by email at

[email protected].

All camp fees are due by June 1, 2012.

Father/Guardian #2_________________________________ Home Phone (___)__________________________

Cell Phone # (___)_________________________ Work Phone # (___)_____________________

Home Adress__________________________________City__________________State_____Zip_______________

Mother/Guardian #1_________________________________ Home Phone (___)__________________________

Cell Phone #(___)_________________________ Work Phone#_____________________

Home Adress_____________________________________City________________State_____ Zip_____________

___ I have included the $100/$50 deposit towards my camper’s overall balance. ___ I have included the $100/$50 deposit plus an additional $______ towards my camper’s overall balance.

___ I have included $______ towards my camper’s store account. TOTAL ($):_______

mailto:[email protected]

Camp Session Sign up

The chart on the following page shows all programs that we have available for the summer.

Within the chart, please check the white box corresponding with the camp of your choice.

When turning in this application, please include the initial deposit of $100 for Resident

Camp and $50 for Day Camp. This deposit will go towards your overall camp balance.

There is also the option of providing your camper with money for the camp store. When your

application and fee have been processed, you will receive a confirmation letter or email

including our parent pack. If you have any further questions, please call (910) 425-3529 ext.

23.

All paperwork is due on the registration day for your camp.

June

11-

15

June

18-

22

June

25-

29

July

2-6

July

9-1

3

July

16-

20

July

23-

27

July

30 –

Aug

. 3

Aug

. 6-1

0

Aug

. 13-

17

Day Camp

I verify that all of the above information is true and correct to the best of my knowledge.

Signature_____________________________________________________________________ Date______________

Resident Camp

June

10-

16

June

17-

23

June

24-

30

July

1-7

July

8-1

4

July

15-

21

July

22-

28

July

29 –

Aug

. 4

Aug

. 5-1

1

Aug

. 12-

18

Traditional Survivor

Night Owls Roller Coaster

Extreme Explorers Outbounders

Water Kayak Venture W.Y.L.D. Bunch

Footprints Family Camp

For office use only: / / __ Balance$_________ Date Deposit Received: ________

__paid in full ___Credit Card __Check #______ Date Balance Paid: _______

Legend:

White Space denotes open week of camp Grey space denotes closed week of camp

Chart Key:

- White boxes indicate which

weeks of programs are available.

- Gray Boxes indicate which

weeks programs are closed.

June

17-

20

June

20-

23

July

15-

18

July

18-

21

Mini Camp

Program Prices: Traditional - $445 Survivor - $465 Night Owls - $450 Roller Coaster - $750 Extreme Explorers - $625 Outbounders - $720 Water - $455 Kayak Venture - $490 W.Y.L.D. Bunch - $990 Mini - $205 Day - $150

Cam

per Nam

e ___

First

Middle

Last ___________________________________________________________________ (For C

amp U

se) Cabin or G

roup____________________ (For Cam

p Use) S

ession Code(s): ________________

Dates will attend camp: from ______________to_____________ Month/Day/Year Month/Day/Year

Camper Name: _____________________________________________________________ First Middle Last

� Male �� Female ��Birth Date ____________ Age on arrival at camp: ________ Month/Day/Year

To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed.

1) Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy. 2) Send the original, signed FORM 1 to camp by the requested date. 3) Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the

copy of FORM 1 with FORM 2 to your child’s health-care provider for review and completion. 4) After it has been completed and signed by your child’s health-care provider, return FORM 2 to

camp by the requested date.

Camper Home Address: ______________________________________________________________________________________________________ Street Address City State Zip Code

Parent/guardian with legal custody to be contacted in case of illness or injury: Relationship Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Email: _______________________

Home Address: _____________________________________________________________________________________________________________ (If different from above) Street Address City State Zip Code

Second parent/guardian or other emergency contact: Relationship Name: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Email: _______________________ Additional contact in event parent(s)/guardian(s) can not be reached:

Relationship Name(s): __________________________ to Camper: ________________ Preferred Phones: (______) ________________(______)_________________

Medical Insurance Information:

This camper is covered by family medical/hospital insurance � Yes � No

Include a copy of your insurance card if appropriate; copy both sides of the card so information is readable. Insurance Company______________________________ Policy Number___________________________

Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________ �Parent/Guardian Authorization for Health Care:

This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate in all camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests, and treatment related to the health of my child for both 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 injection, anesthesia, or surgery for this child. I understand the information on this form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

Signature of Custodial Relationship Parent/Guardian __________________________________________________________________Date: to Camper: _______________________

If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Page 1/4

Restrictions: � I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. � I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)

Diet, Nutrition: � This camper eats a regular diet. ��This camper eats a regular vegetarian diet. � � � � This camper has special food needs. (Please describe below.)

Allergies: � No known allergies. � This camper is allergic to: � Food � Medicine � The environment (insect stings, hay fever, etc.) � Other (Please describe below what the camper is allergic to and the reaction seen.)

Mail this form to the address below by _______ (date)

CAMPER HEALTH HISTORY FORM 1 Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses


Camper Name: ________________________________________________ First Middle Last Birth Date: ____________

Month/Day/Year

Immunization History: Provide the month and year for each immunization. Starred (�) immunizations must be current. Copies of immunization forms from health-care providers or state or local government are acceptable; please attach to this form.

Immunization Dose 1 Month/Year

Dose 2 Month/Year

Dose 3 Month/Year

Dose 4 Month/Year

Dose 5 Month/Year

Most Recent DoseMonth/Year

Diptheria, tetanus, pertussis� (DTaP) or (TdaP)

Tetanus booster� (dT) or (TdaP)

Mumps, measles, rubella��(MMR)

Polio��(IPV)

Haemophilus influenzae type B (HIB)

Pneumococcal (PCV)

Hepatitis B

Hepatitis A

Varicella �Had chicken pox (chicken pox) Date:

Meningococcal meningitis (MCV4)

Tuberculosis (TB) test Date: � Negative � Positive If your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from not being fully immunized.

Signature of Custodial Relationship Parent/Guardian: ______________________________________________________________Date: to Camper: __________________________

Medication: � This camper will not take any daily medications while attending camp. � This camper will take the following daily medication(s) while at camp:

"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review camp instructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper’s name and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp. Name of medication Date started Reason for taking it When it is given Amount or dose given How it is given �Breakfast

�Lunch �Dinner �Bedtime �Other time:_____________

� �

�Breakfast �Lunch �Dinner �Bedtime �Other time:_____________

� �

�Breakfast �Lunch �Dinner �Bedtime �Other time:_____________

� �

The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury. Cross out those the camper should not be given.

Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed) Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin) Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM) Sore throat spray Generic cough drops Lice shampoo or cream (Nix or Elimite) Antibiotic cream Calamine lotion Aloe Laxatives for constipation (Ex-Lax) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)

Copyright 2008 by American Camping Association, Inc. Page 2/4 Rev. 1/2007 LEE/EAW



Month/Day/Year

General Health History: Check "Yes" or "No" for each statement. Explain “Yes” answers below.

Has/does the camper:

1. Ever been hospitalized? …………………………. � Yes � No 11. Had fainting or dizziness? ..................................................... � Yes � No

2. Ever had surgery? .............................. …………. � Yes � No 12. Passed out/had chest pain during exercise? ….……………. � Yes � No

3. Have recurrent/chronic illnesses? .......……….… � Yes � No 13. Had mononucleosis ("mono") during the past 12 months?... � Yes � No

4. Had a recent infectious disease? ....... …………. � Yes � No 14. If female, have problems with periods/menstruation?.…….. � Yes � No

5. Had a recent injury? ........................... …………. � Yes � No 15. Have problems with falling asleep/sleepwalking? ............... � Yes � No

6. Had asthma/wheezing/shortness of breath?...... � Yes � No 16. Ever had back/joint problems?…….………...……………...... � Yes � No

7. Have diabetes? .................................. …………. � Yes � No 17. Have a history of bedwetting?………………….……………... � Yes � No

8. Had seizures? .................................................... � Yes � No 18. Have problems with diarrhea/constipation?……………….... � Yes � No

9. Had headaches? …………………………………. � Yes � No 19. Have any skin problems?…………………….......................... � Yes � No

10. Wear glasses, contacts, or protective eyewear? � Yes � No 20. Traveled outside the country in the past 9 months?.............. � Yes � No Please explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visited and dates of travel.

Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records.


What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important or that may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed.

Health-Care Providers:

Name of camper’s primary doctor(s): ____________________________________________________ Phone: (________) _______________________

Name of dentist(s):___________________________________________________________________ Phone: (________) _______________________

Name of orthodontist(s):_______________________________________________________________ Phone: (________) _______________________

Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.

Has the camper:

1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ………………………........ � Yes � No

2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……............................................................................. � Yes � No

3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. � Yes � No

4. Had a significant life event that continues to affect the camper’s life?...................................................................................................... � Yes � No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others) Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.



Month/Day/Year


Individual Health Record (For Camp Use Only) Initial Screening Date/Time: _________ Initials: ____________

��Screening has been conducted according to camp protocol and significant findings noted as follows:

A. Any signs/symptoms of illness or injury upon arrival?........................ � No � Yes as noted below

B. History of exposure to communicable disease?.................................. � No � Yes as noted below

C. Additions or corrections to information on this health history?............ � No � Yes as noted below

D. Medication given to health-care staff?.................................................. � No � Yes as noted below

E. Any signs/symptoms of head lice?...................................................... � No � Yes as noted below

Provider notes: (date/time/initial all entries) _____________________________________________________________________________

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____________________________________________________________________________________________________________________ Exit Note: Check one of the following:

� Left camp this day with no reported illness or injury symptoms.

� Left camp this day with the following problem/concern:

_____________________________________

________________________________________________________________________________________________________________

This person was told about the problem and instructed about follow-up as noted above: __________________________________________

Date/Time: ___________ Initials: __________

Cam

per Nam

e ______________________________________________________________________ (For Cam

p Use) C

abin or Group____________________ (For C

amp U

se) Session C

ode(s): ________________

First

Middle

Last

Do you feel that the camper will require limitations or restrictions to activity while at camp?�� No � Yes

“I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’s parent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except as noted above.) Name of licensed provider (please print): __________________________________Signature: _________________________________Title: _________

Office Address_____________________________________________________________________________________________________________ Street City State Zip Code

Telephone: (________)_____________________ Date:_______________________

If you answered “Yes” to the question above, what do you recommend? (describe below—attach additional information if needed)

CAMPER HEALTH-CARE RECOMMENDATIONS by LICENSED MEDICAL PERSONNEL FORM 2

Developed and reviewed by: American Camp Association, American Academy of Pediatrics Council on School Health, & Association of Camp Nurses

Mail this form to the address below by _______ (date)

Allergies: � No Known Allergies

� To foods (list):

� To medications: (list):

� To the environment (insect stings, hay fever, etc.– list):

� Other allergies: (list):

Describe previous reactions:

Diet, Nutrition: � Eats a regular diet. � Has a medically prescribed meal plan or dietary restrictions:(describe below)

Medication: � No daily medications. � Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe below)

�

The following non-prescription medications are commonly stocked in camp Health Centers and are used on an as needed basis to manage illness and injury. Medical personnel: Cross out those items the camper should not be given.

Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin) Phenylephrine (Sudafed PE) Pseudoephedrine (Sudafed) Chlorpheneramine maleate Guaifenesin Dextromethorphan Diphenhydramine (Benadryl) Generic cough drops Chloraseptic (Sore throat spray) Lice shampoo or scabies cream (Nix or Elimite) Calamine lotion Bismuth subsalicylate (Pepto-Bismol) Laxatives for constipation (Ex-Lax) Hydrocortisone 1% cream Topical antibiotic cream Calamine lotion Aloe

Weight: _______ lbs Height: _____ft_____in Blood Pressure_______/_______

Other treatments/therapies to be continued at camp: (describe below) � None needed.

The camper is undergoing treatment at this time for the following conditions: (describe below) � None.

Physical exam done today: � Yes � No (If “No,” date of last physical: ___________) Month/Day/Year

ACA accreditation standards specify physical exam within last 24 months.

Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete all remaining sections of this form (FORM 2). Attach additional information if needed.

Copyright 2008 by American Camping Association, Inc. Rev. 2/07 LEE/EAW

To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of your completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review.

Dates will attend camp: from ______________to_____________ Month/Day/Year Month/Day/Year

Camper Name: _____________________________________________________________ First Middle Last

� Male �� Female ��Birth Date ____________ Age on arrival at camp ________ Month/Day/Year

Camper home address: ________________________________________________________

____________________________________________________________________________ City State Zip Code

Custodial parent(s)/guardian(s) phone: (_______)______________ (_______)____________ Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.

PARTICIPATION ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS and RELEASE AND INDEMNITY AGREEMENT

In consideration of the services of Camp Rockfish, and its chartering organization, NC United Methodist Camp & Retreat Ministries, INC., and each of their respective agents, employees, officers, directors, trustees, affiliates, representatives, independent contractors, volunteers (including consulting physicians), and any and all other persons or entities acting under their direction and control associated with them (collectively referred to as “ROCKFISH”), participant (and parent or guardian of a participant) acknowledges and agrees as follows:

ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS

I understand that participant and parents share the responsibility for participants’ safety, for managing the risks and for determining the participant’s suitability for the program in which he/she will participate. I have accurately completed any required ROCKFISH application and medical forms and have reviewed all ROCKFISH program information provided to me. I agree to have my child obey all ROCKFISH rules, regulation and policies. My child has no mental or physical problems or limitations that might affect my child’s ability to participate that have not been disclosed to ROCKFISH in writing, I have had the opportunity to ask question about the program activities and the risks of the program in which my child will participate.

I understand and acknowledge that the program(s) in which my child will participate has risks and it is impossible to anticipate every activity in which my child will engage. The activities will depend on the program but may be physically strenuous. These activities may be instructional, educational, or adventurous and may include but are not limited to: hiking, archery, BB guns, skate park, camping, including cooking over stoves, open fires or by other means; ropes and/or challenge courses (traversing ropes suspended off the ground, potentially at great heights, zip lines and other such activities); physical problem-solving activities; rock, wall or tower climbing; repelling; water activities including rafting, canoeing, kayaking, or swimming; vehicle travel, and rescue scenarios (real or simulated). I understand that my child may engage in other activities not listed above. Activities may take place in North Carolina or the United States. Participants may also be in urban or other areas with exposure to individuals who are not under ROCKFISH’s supervisions or control. The planned program may be modified for any number of reasons, including convenience, weather, emergencies or unexpected conditions.

It is impossible to know or list every risk associated with every activity. Some, but not all, of the risks my child may encounter include: unpredictable or harsh weather; lightning exposure to extreme temperatures (high heat or cold); drowning; wild animals and marine life; improper or malfunctioning equipment; slipping, falling or being struck by objects or persons; risks caused or complicated by any mental, physical or emotional conditions any participant may have; physical contact with other participants or other individuals; and other natural or man-made hazards. Another risk is the potential misjudgment by ROCKFISH instructors, volunteers, other staff members, co-participants or contractors related to my child’s participation, including but not limited to decisions regarding my child’s physical condition and capabilities, weather, water, terrain, route or medical treatment. All of these risks are inherent to the activities in ROCKFISH’s program, which means that they cannot be changed or eliminated without altering the essential elements of the activity.

I acknowledge that participating in an ROCKFISH program involves inherent risks and other risks, hazards and dangers including some not listed above that can cause or lead to death, injury, illness, property damage, mental or emotional trauma, or disability. Furthermore, activities may take place several hours or days from any medical facility or where communication, transportation, or evacuation is subject to delay. I understand that ROCKFISH cannot assure my child’s safety and does not seek to eliminate all of these risks of the activities of my child’s ROCKFISH program, whether inherent to not whether described or not.

ADVENTURE WAIVER Rockfish Camp & Retreat Center

Parent/Guardian Initials: _______________ Participant Initials: _______________

RELEASE AND INDEMNITY AGREEMENT

I release ROCKFISH from, and agree not to pursue claim or sue ROCKFISH for, any liability, claim, suit or expense in any way associated with my child’s enrollment or participation or the use of any equipment or facilities in the ROCKFISH program. Neither I nor anyone acting on my child’s behalf will make a claim against ROCKFISH as a result of any loss, injury, illness, damage or death suffered by my child. This release includes any losses caused or alleged to be caused, in whole or in part, by the negligence of ROCKFISH to the fullest extent by law and includes claims for breach of contract or any other type of suit. I do not waive any claims for gross negligence or willful or wanton conduct.

I further agree to defend and indemnity ROCKFISH (to pay or reimburse ROCKFISH for money it is required to pay, including attorney’s fees and costs) with respect to any and all claims brought by or on behalf of me, my child, a family member, a co-participant, or any other person for any claims related to my child’s participation in the program or my child’s use of equipment or facilities, including claims that ROCKFISH instructors, staff, or volunteers were negligent. However, I do not agree to indemnity ROCKFISH for claims of gross negligence or willful wanton conduct.

ADDITIONAL PROVISIONS

I agree that the substantive law of North Carolina governs this document and any dispute or suit I have (or my child has) with ROCKFISH regardless of the “conflict of law” rules.) Any mediation, suit, or other proceeding must be filed or entered into only in North Carolina. I agree to pay all attorney’s fees and costs incurred by ROCKFISH in defending a claim or suit if the claim is withdraws or to the extent a court determines that ROCKFISH is not liable for the injury or loss.

The assumption of risks, release, indemnity agreement, and all other provisions in this document are intended to be interpreted and enforces to the fullest extent allowed by the law. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect of the enforceability of the remaining provisions, which shall continue in full force and effect. ROCKFISH has permission to use my child’s photo or image for sale or reproduction in any manner it desires, including advertising or display. ROCKFISH reserves the right to remove any participant from the program when staff or an instructor believes, in his/her sole discretion, the participant presents safety concern or medical risk, is disruptive or acts in any manner detrimental to the program. If my child is dismissed or departs for any reason, I will be responsible for all costs of early departure whether for medical reason, dismissal, personal emergencies, or otherwise.

I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT, I UNDERSTAND THAT I AM SURRENDING CERTAIN LEGAL RIGHS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, MY MINOR CHILDREN AND OTHER FAMILY MEMBERS, AND MY HEIRS, EXECUTORS, REPRESENTATIVES AND ESTATE.

If participant is under the age of 18 at the time this document is signed, a parent or legal guardian must sign the release in addition to the participant’s signing.

Participant’s Printed Name: ____________________________________________________________________________________________________________

Participant’s Signature: _______________________________________________________________________________________________________________

Date: _____________________ Phone: __________________________________________ Date of Birth: ____________________________________________

Address: _____________________________________________________ City: ________________________ Sate: ___________ Zip: _____________________

TO READ AND SIGN BY PARENT/GUARDIAN OF MINOR I hereby represent that I am the parent or guardian of the minor whose name appears above, I have read and consent/agree to the terms and conditions herein,

on behalf of said minor and myself.

X_____________________________________ _______________________________________ ________________ Guardian Signature Print Name Date

Camper Behavior Contract

1. I want to be a camper at Camp Rockfish. 2. I will respect myself, my fellow campers, camp staff and camp property. 3. I will wear the proper safety gear at all times when instructed to do so. 4. I will use positive language to others. 5. I will refrain from negative physical behavior towards myself, my fellow campers, camp staff and camp

property. 6. I understand that if I do not follow this behavior contract, I may have to leave camp early.

Camper Signature: Date:

Parent/Guardian Signature: Date:

Photo & Video Release

Camper Name (print):

I grant Rockfish Camp and Retreat Center(RC&RC), its representatives and employees the right to take photographs of my camper and their property in connection with RC&RC activities and programs. I authorize Rockfish Camp and Retreat Center, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Rockfish Camp and Retreat Center may use such photographs of my camper with or without his/her name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content. I have read and understand the above. Parent/Guardian Signature: Date:

Parent/Guardian Name (print):

Rockfish Camp & Retreat Center 226 Camp Rockfish Road

Parkton, NC 28371 910-425-3529

www.camprockfish.org

Pick-Up Release

Camper’s Name:

□ My camper will be leaving camp during normal check-out time.

□ My camper will need to leave camp early due to an unchangeable scheduling conflict.

Along with myself, the following person(s) are authorized to pick-up ___________________ from Rockfish Camp and Retreat Center. camper name

Name: Daytime Phone #:

Address: Cell Phone #:





I understand that Rockfish Camp and Retreat Center will only release my camper to the persons listed above in addition to myself after I/they display a valid driver’s license with a name that matches what I listed above. Name (print): Cell Phone #:

Signature: Date:


Parkton, NC 28371 910-425-3529

www.camprockfish.org

Rockfish Camp & Retreat Center is a ministry of the NC Methodist Camp & Retreat Ministries, Inc., which is an independent 501(c)(3) nonprofit organization,

responsible for it’s own debts and obligations. We are related by faith to the NC Conference of the United Methodist Church. Tax ID# 56-2138935


Parkton, NC 28371 910-425-3529

www.camprockfish.org [email protected]

Rockfish Camp Store Account Balance Form

Please tell your camper how much you have deposited in their camp store account and discuss with them how they should spend it. On checkout day, the camp store will be open so that you and your child may use any remaining balance for store purchases, or you may choose to have any balance remaining deposited into our Campership Fund.

Please complete the following:

My camper, _____________________________________________, is aware that his/her initial store

balance is: $_____________________.

Please allow any remaining store balance to be:

____ Donated to Camp Rockfish’s Campership Fund.

____ Spent in the camp store at checkout.

Parent’s Printed Name: ____________________________________________________________________

Parent’s Signature: _________________________________________ Date: ________________________

If you have a particular concern regarding the distribution of your camp store balance, please contact our office manager.

(For office use only)

Store Balance: _______________ Donation to Campership Fund: _________________ Clerk: ________________

Stay in touch this summer with

One-Way Camper Email!

QUESTIONS OR PROBLEMS? Please call Bunk1 at 1-800-216-9472 or go to www.bunk1.com/contact.asp

We are excited to tell you about our partnership with Bunk1.com! Bunk1’s secure, easy to use, summer website services let you stay in touch with your camper all summer!

GET STARTED TODAY

To set up a new account and visit our Online Community: 1. Go to our website at www.camprockfish.org and click “Summer Camp” (left side) 2. Click the flashing “Camper Email” button * 3. Click “Register Now” 4. Enter your Pre-Approved Registration Code: 1210168RF 5. Fill out all the required information 6. Purchase Bunk Note credits (you will need a credit card) 7. Send an email to your camper! * If you cannot find this button, go to www.camprockfish.bunk1.com instead and continue on to the next step ** For your camper’s safety, please do not share the Pre-Approved Registration code above. FREQUENTLY ASKED QUESTIONS How do I send a Bunk Note (one-way email) to my camper? Follow the instructions above except, after registering, simply sign in and click on the Bunk Notes button. Enter your camper’s name, select the correct cabin, type your message, and hit the “Send” button. Why do I have to pay to send Bunk Notes (one-way email)? Each morning, the Bunk Notes system bundles and sorts the messages for us to print out and distribute to campers. It also protects us from computer viruses and allows us to easily manage these emails. Your payment helps us cover the cost of the system, paper, ink, and labor and, more importantly, frees us to do what we do best

– be with your kids! Bunk Note credits cost $1 each and are purchased in packs of various sizes. Can other relatives use these services? Certainly. Once you have set up your account, you will be able to invite other people to access these services. What do I do if I lost my username and password? You can get it online by going to www.Bunk1.com and clicking on the link "Lost Your Password?" (to the left of the page below the sign in button). You will receive an email with your username and password within a few minutes.

http://www.camprockfish.bunk1.com/

ASYMCA Camp Rockfish Application Documents

Sports

Transcript of ASYMCA Camp Rockfish Application Documents