OHF Camp Independence 2012 - Register for Camp!

Student Registration

Camper's Full Name * First, MI, Last

Sex *

Male
Female

Permanent address *

City,State,Zip *

E-mail address

Birth Date * MM/DD/Year

Home Phone *

Cell Phone *

Parent/Guardian * First, Last

How to be reached in an emergency *

Name of Emergency Contact if Parent/Guardian are not available. * Fist, Last

Relationship to Camper *

Home phone *

Cell phone *

Bleeding disorder? *

Yes
No, I am a sibling

Type/Severity/Factor level *

Pick up/Drop off location * please mark the closest to where you live.

OKC
Tulsa

Camper Registration Fee of $20 per camper (maximum of $50 per family*). This fee will be used to offset the cost of tee shirts and to help fund the OHF International sister camp in Mexico City *

Please make all checks/money orders payable to the Oklahoma Hemophilia Foundation and include with completed application.

*To qualify for fee maximum family members must live in same household.

Indicate if you are sending a check for registratrion fee or participating in Coins4Camp. *

Check (please make checks/money orders payable to the Oklahoma Hemophilia Foundation) Due May 1, 2011
Coins4Camp (must be at least $20.00)

Are there any special needs or acommondations including diet restrictions? *

If yes, please list.

Does your child wear

glasses
contact lenses
hearing aids
ear plugs while swimming

To help prevent ear infections after swimming, we use ear drops of vinegar and alcohol. Do you want your child to receive ear drops? *

Does your child want to learn self infusion? *

I Give My Permission for my camper to take part in all camp activities except as documented on the Medical History form. In consideration of the benefits derived from my childÕs attendance at Camp Independence, I expressly waive all claims against the camp and itÕs staff, the Oklahoma Hemophilia foundation, officers, and board members on account of any accident, injury and/or illness that may occur to my child during camp.

Photo Release

We annually make a camp video to give to each camper as well as help promote Camp Independence and other OHF activities. We have on occasion been asked to use a picture from camp in various national magazines to help promote our camp. Full names will not be used when we release a picture. We will only allow for first names to be used. We would like permission to be able to use any images taken during camp for that purpose.

I understand that pictures and videos will be taken during Camp Independence. I agree to participate in camp videos and pictures. I understand that any image in print and/or videotape of me may be released with my first name.

Camper's full name * First, MI, Last

Age as of June 1, 2011 *

Sex *

Male
Female

Please answer questions to the best of your ability. *

	No	Yes
Does your child want to come to camp?
Have they ever been to camp before?
Have they been away from home before?
Do they need help making friends?
Is behavior at home/school good?
Do they have a problem with temper or acting out?
Do they currently experience bed-wetting?
Do they sleepwalk or have sleep problems?
Are you concerned they may get homesick?

Please write below any issues that you think the camp staff should be aware of.

Please list the names and age of applicant's siblings that will be attending Camp Independence this year. Each camper must have an application filled out.

Everyone wants to have fun at camp. Before you come, these are basic rules everyone must promise to follow:

I promise to be on my best behavior.

I understand that I can be sent home from camp for bad behavior (not following directions or fighting)

Cursing, swearing, fighting, and teasing are not allowed.

I promise that I will not steal, damage, or destroy anyoneÕs property.

Tobacco, matches, lighters, illegal drugs and alcohol are not allowed at camp. I will not bring these to camp.

I will not bring guns, pocket knives, or weapons of any kind.

I will not bring electronic games, toys, radios, CD players, MP3, IPODs, pagers, or phones to camp. The camp director or medical staff will help me if I need to make an emergency phone call.

If I have any problems at camp, I understand that I can go to my counselor, or Camp director.

I agree to follow all of these rules and the rules of my cabin at camp as well as any rules set by the Camp grounds. I understand I will be sent home from camp at my own expense if I break any of these rules.

Camp Policies and Behavior:

I understand that my child may be sent home from Camp Independence if he/sheÕs behavior is deemed harmful to the camp community. I acknowledge that I will be held financially responsible for any act of vandalism caused by my child. I acknowledge that Camp Independence is not responsible for the loss, damage, or theft of my childÕs property. I have read and understand the above camperÕs contract.

A Letter to My Counselor

My name is *

My friends call me

When I get to camp, I will be * please put your age.

And I will be going into the * Please put what grade you are going into (Ex. 3rd grade).

I enjoy * list anything you enjoy.

I don't like to * list anything you do not like.

At school I like to *

I want to go to Camp Independence because *

Something I want you to know about me is *

Camper's Name * Last, Fist, MI

Birth Date * MM/DD/Year

Answer the following questions *

	Yes	No
Have any members of your family under age 50 had a "heart attack" or "heart problems"?
Have you ever been told you have a heart murmur, high blood pressure, or heart abnormality?
Do you ever have to stop while running 1/2 mile because of shortness of breath or severe chest pain?
Have you ever passed out or been knocked out (fainting, concussion)?
Have you ever had any illness or injury that required emergency medical or surgical attention or lasted longer than one week?
Have you ever had any illness or injury that caused serious reaction due to an insect sting or medications?

Do you have any allergies? *

If yes, please list cause and type of reaction (rash, wheezing, breakout)

Females only: Menses started Please add age of onset too.

Please list any activity restrictions while at camp. *

List all prescriptions and over the counter medicines your child will be bring to camp: factor and Stimate included. This is an active camp. Even campers with mild bleeding disorders need to bring their treatment product(s). All medications must be given to medical staff before boarding the bus (only asthma inhalers allowed in cabins). Please indecate Medicine/Factor, Dose, Schedule, and Reason for taking.

EMERGENCY MEDICAL RELEASE

I grant permission for my child to receive treatment for their bleeding disorder (if any) and any other medical problems while at camp. In the event of a medical emergency, I grant permission for my child to be transferred to a medical facility for treatment at the discretion of the camp medical staff. I will be responsible for all cost incurred for emergency, inpatient, or outpatient care. I understand that my child will be covered solely by the medical insurance policy in which he/she is currently enrolled. I authorize a licensed medical professional to dispense any medication recommended or prescribed by a physician for my child.

In case of a medical or surgical emergency, I authorize Camp Independence medical staff to treat my child or to arrange for my child to receive any x-ray, anesthetic, medical, dental, surgical procedure, treatment and hospital care which is deemed advisable by and is to be rendered under the supervision of any physician, dentist, or surgeon licensed in Oklahoma.

Name of Insurance Company

Policy #

Group #

Name of Policy Holder

SSN

PHYSICAL EXAMINATION

You can print the "Physical Examination" under Registration tab to have completed by your child's physician. Physical Examination form with Registration fee (unless your child is participating in Coins4Camp) must be mailed by May 1, 2011. Mail to: Oklahoma Hemophilia Foundation Attn: Camp Independence 720 W. Wilshire Blvd. Suite 101B Oklahoma City, OK 73116

Digital Signature *

Oklahoma Hemophilia Foundation

Contact

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