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John and Sandy Cafourek
Camp Director
(503) 587-7053
[email protected]
Northwest Preteen Camp 2015
Camper & Staff Information/Packing List
Dates:
Application Due: May 1, 2015 (Add $15 if received after deadline)
Camp: Sunday, August 2 – Wednesday, Aug 5, 2015
Fees:
Camper - $120
Additional Campers in same family - $90
Teen Staff (13-19) - $40
Adult Staff (20+) - $20; Add $15 if late
Make checks out to “United Church of God – Salem”
Mail Applications to:
United Church of God - Salem
PO Box 5965
Salem, OR 97304
Theme:
Let Your Light Shine, Matthew 5: 14, 16
Location: Camp Arrah Wanna, Welches, Oregon
http://www.camparrahwanna.org/index.html
Ages:
Campers may participate at camp between the ages of 6 and 12 years of age.
Activities: Daily Christian living, archery, swimming, arts and crafts, sports, river float,
dance, campfire, etc.
Changes/Cancellations:
To make any changes or to cancel your camp application, please notify the
directors as soon as possible.
Arrival:
Arrive at 4 p.m. and park at the Pavilion parking lot.
Check List
What to bring to Northwest Preteen Camp 2015
MARK ALL YOUR ITEMS WITH YOUR NAME or INITIALS
□ Medicines in ORIGINAL CONTAINERS!!!
□ Campfire ideas for quick skits, songs, dances, talent show and costumes to match,
group songs, etc.
□ CAMPERS: T-shirts from other NW preteen camp years (if you grew out of them; you
can pass them on to other campers.)
□ Shorts (denim, khaki, gray, black, tan)
□ NEW! Two swimsuits:: one for river float, one for the pool (one-piece suit for girls and
staff, modest for all)
□ Sneakers—flip flops are not appropriate for a lot of walking at camp
□ Aqua socks/shoes for the river float. Flip flops may float away.
□ Toothpaste/toothbrush
□ Sunscreen, hat or cap for sun, jacket for rain/umbrella
□ Bar of soap and shampoo
□ Sleeping bag/warm camping type, not sleep-over for indoors, or send blankets/quilts
and a pillow.
□ Hair brush/comb/hair dryer
□ Disposable Camera (optional)
□ Towels and washcloths
□ Plastic bag for wet clothes
□ Chap stick or lip balm
□ Kleenex
□ Warm jackets, jeans/sweats (It can be cold in the forest.)
□ Bible, pen, pencil
□ Optional: Lights, flashlights, reflectors,
Camper Application Form
for Preteen Camp _____________
a United Youth Camps
Attach
Sponsored by: United Church of God, IA
Recent Photo
Here
See attached documents or
http://uyc.ucg.org for details
Note: Application cannot
be processed without
a recent photo
GENERAL INSTRUCTIONS:
 Fill Out the Form(s) Completely. Some fields will automatically copy to other places in
the document.
 Include Your Payment. Make checks payable to the fund instructed online.
 Be On Time. Mail to the address specified on the website by the deadline, otherwise late --------------------------------------------------------------fees apply.
Date of Photo:
 Other Forms: Please review the website and submit ALL additional forms in order for
your application to be complete.
Tracking Box
PERSONAL INFORMATION
(for office use only)
Applicant's Last name (print):
First
Middle
Last grade completed before camp:
Sex:
Date Received:
Amount Paid:
Health History/Exam Form Rec’d?
Transportation Form Rec’d?
Ministerial Evaluation Rec’d?
Acceptance Letter Sent?
 Male  Female
Address:
City:
Birth Date:
State:
/
/
Zip:
Age by 1st day of camp:
Home Phone number: ( _ _ _ )) _ _ _ - _ _ _ _
Mobile Phone Number: (( _ _ _ )) _ _ _ - _ _ _ _
Work Phone Number: (( _ _ _ )) _ _ _ - _ _ _ _
Parent’s E-mail:
Congregation:
Pastor's name:
Does youth attend the United Church of God services regularly?  Yes
Youth wears children’s T-shirt Size (Select One)
S
M L
Has youth attended overnight United Youth Camp before?
Swimming proficiency*:
 Can't swim
OR
 No
Adult T-shirt Size
 Yes  No
 Beginner
If no, other church?
S
M
L XL
If yes, list most recent camp/year.
 Intermediate  Skilled
*not applicable to all camps
HEALTH AND ADDITIONAL INFORMATION
Does youth have any health problems, disabilities, severe allergies or any other condition that may require treatment at camp or that could limit their camp
experience and full participation?  Yes  No
If yes, please explain (attach note if needed for full explanation):
Summarize any on-going medical care or medication you are taking (if none, state "NONE"):
Is youth willing to be a FULL PARTICIPANT in camp (except for health limitations noted above)?
Is there anything else you would like us to know prior to camp?
 Yes  No
AGREEMENT AND RELEASES
Compliance with Rules: All United Camps maintain a high standard of conduct and dress, based on God’s laws, which is further stated in
the Code of Honor. These standards and rules include, but are not limited to: No possession or use of alcohol, tobacco or illegal drugs; no
sexual misconduct, theft, smoking, disorderly conduct, profanity, destruction of property or refusal to cooperate fully with the camp staff.
Jewelry for body piercings (other than earrings for girls), short shorts, midriffs, halter-tops or wearing revealing or other inappropriate apparel
(or lack thereof) will not be allowed. Hair should not be an unnatural color, and hair length should be appropriate (short for boys, longer for
girls). Pets, personal sports equipment and camper use of private vehicles are not allowed at camp, except as noted in the acceptance
package. Firearms or other weapons (including pocketknives) may not be brought without the written permission of the camp director.
Under certain circumstances I am aware that a search of my belongings or living quarters may be made in my presence by camp staff.
Campers who do not comply with the camp’s rules and standards, or whose conduct or attitude undermines the positive environment and
objectives of the camp, or have made any false, misleading or incomplete statement in this application or the Health History and Examination
Form, are subject to being dismissed. If the camper is dismissed, he/she will be sent home at his or her parent’s expense.
Photo Release: By my/our signature(s) below, I/we also hereby give consent and permission to the nonexclusive, noncommercial
reproduction, publication or use by United Church of God, an International Association (“Church”) or anyone authorized by them, of any
pictures or photographs (still, video or motion, individual or group), taken of the applicant at United Youth Camp or its related activities
(including travel) or, if taken during any other Church-related activities, together with any caption or descriptive material, including the
individual/camper’s name, without compensation to the undersigned. Said picture(s) may be used without limitation, on Church Web site(s),
in Church publications, in “Festival” or other videos or promotions created by the Church, in Church-sponsored advertising, or in any
television program or broadcast approved by the Church.
General release: In consideration of the applicant being allowed to attend the camp, I/we hereby release, indemnify, save and hold
harmless and covenant not to sue the United Church of God, an International Association, its officers, Council of Elders, agents, employees,
volunteers and helpers and any other related entity (hereinafter collectively called the “Church”) from all actions, claims, demands or suits
which are based upon, or result from injuries sustained by the applicant arising out of, or in the course of, said applicant’s participation or
attendance at the camp. This release, however, shall not apply to claims covered by the Church’s liability insurance, but is applicable to
claims not covered by that insurance. It is strongly recommended that you have your own medical insurance protection since participants
are involved in activities at their own risk.
Parent(s) of Minors: Activities of the camp are described in the United Youth Camps annual brochure. I/we have read the
brochure, are aware of the activities offered and hereby give permission for (applicant’s name)__________________________________
to attend camp, to be transported in camp-designated vehicles for any off-site activities and to participate in all the activities (unless
otherwise noted on the Health History Examination Form and in the space on the preceding page). Permission is hereby given to search
camper belongings or living quarters with him/her present when health, well-being or safety of the camper or others require it, or where there
has been an accusation or some evidence of his/her possession or use of forbidden materials or substances. I/we understand that if he/she
violates camp rules or standards or endangers the safety or well-being of the camp, other campers or its staff or otherwise fails to comply
with the foregoing requirements to which he/she has agreed, that he/she can be sent home at the camp director’s request, which, I/we agree,
will be at my/our expense. I/we understand there is no reimbursement of fees after 30 days before camp starts. Before that time, a
processing fee of $40 will be withheld from the refund. I/we believe my/our son/daughter is in good health and can participate in strenuous
activities and the usual routine associated with camp life. I/we verify and concur that the information supplied in this application and on the
Health History and Examination Form is true and complete.
Emergency Contact Information:
Name:_______________________________________ Relationship to Camper: ______________________
(___)___-____
Home:______________________________________
(___)___-____
Cell:______________________________________
(___)___-____
(___)___-____
Work: _______________________________________
Other: ____________________________________
In Camper’s own words, explain why he/she wants to attend this camp:
____________________________________________________________________________________________________
Are you aware of any special needs of your son/daughter such as facilities, medical attention, supervision, or counseling?
If yes, please describe here or on a separate sheet:
 Yes  No
Signatures: I have read, fully understand and agree to the foregoing, including rule compliance, photo and general release statements above.
X
Date
Applicant’s Signature
X
Date
Father’s Signature (if applicant is a minor)
X
Date
Mother’s Signature (if applicant is a minor)
Name
Staff/Camper
For Camp Use
(Circle one)
Dorm
Year
For Camp Use
For Camp Use
Health History Form
for Preteen United Youth Camps
Sponsored by:
United Church of God, an International Association
This form must be completed (all 4 pages) by each person attending camp, or in the case of minors, by their parents or
guardians. PLEASE PRINT.
PERSONAL INFORMATION
Applicant's Name:
Sex: ○ Male ○ Female
First
Address:
Middle
Street Address
Last
City
State
Zip
Birth Date:
/
/
Phone: (( _ _ _ )) _ _ _ - _ _ _ _
Last Four Digits of Social Security Number of Participant: XXX – XX –
Parent/Guardian or Emergency Contact:
Telephone: ( _ _ _) ) _ _ _ - _ _ _ _
Home
Relationship:
(( _ _ _) ) _ _ _ - _ _ _ _
Work
Second Parent/Guardian/Emergency Contact:
Telephone: (( _ _ _) ) _ _ _ - _ _ _ _
(( _ _ _) ) _ _ _ - _ _ _ _
Other
Relationship:
( _ _ _) ) _ _ _ - _ _ _ _
Home
(( _ _ _) ) _ _ _ - _ _ _ _
Work
Other
INSURANCE INFORMATION
Please furnish the following medical and insurance coverage information:
Insurance Company:
Policy or Group #
Social Security Number of Policyholder or Insurance ID Number:
Insurance Phone # (( _ _ _) ) _ _ _ - _ _ _ _
Policyholder Date of Birth:
Address:
Phone: (( _ _ _)) _ _ _ - _ _ _ _
Family Physician:
Address:
Family Dentist/Orthodontist:
Phone: (( _ _ _) ) _ _ _ - _ _ _ _
Address:
MEDICAL HISTORY
Many activities such as sports and challenge courses require participating in physical exercises that are physically demanding. Do
you have health problems or disabilities that might hinder you from participating fully in camp activities? ○ Yes ○ No
If yes, please describe in detail (attach note if necessary):
HH2013
Preteen United Youth Camps Health History Form
Page 1 of 4
.
Do you have any severe allergies (including food allergies) or any other condition or limitation that could affect your camp experience?
○ Yes ○ No If yes, please explain (attach note if necessary):
Are you allergic or sensitive to any medicines or other substances?
and its management:
○ Yes ○ No
If yes, please list and describe the reaction
Medications Being Taken
Are you taking any medications (including over-the-counter or other nonprescription drugs) routinely?
○ Yes ○ No
If yes, please list all medications (including over-the-counter or other nonprescription drugs) taken routinely. Be sure to bring your
medication with you in the original packaging that will identify the doctor, the dosage and the frequency of administration:
Medication
Dosage
Frequency
Reason for Taking
Health History – Explain any “yes” answers below
Has/does the participant:
YES
1. Had any recent injury, illness or infectious
disease? .............................................................. □
2. Have a chronic or recurring illness/condition?....... □
3. Have frequent headaches? ................................... □
4. Wear glasses, contacts or protective eye wear? ... □
5. Ever had frequent ear infections? ......................... □
6. Ever passed out during or after exercise?............. □
7. Ever been dizzy during or after exercise? ............. □
8. Ever had seizures?................................................ □
9. Ever had chest pain during or after exercise? ....... □
10. Ever had high blood pressure? ............................. □
11. Ever been diagnosed with a heart murmur? ......... □
12. Ever had back problems?...................................... □
NO
□
□
□
□
□
□
□
□
□
□
□
□
YES NO
13. Have an orthodontic appliance being brought
to camp?.............................................................. □
14. Have any skin problems (e.g., itching, rash,
acne)?.................................................................. □
15. Have diabetes? ..................................................... □
16. Have asthma? ....................................................... □
17. Had mononucleosis in the past 12 months? ......... □
18. Have problems with sleepwalking? ....................... □
19. Have a current history of bed-wetting? ................. □
20. Have an eating disorder? ...................................... □
21. Ever had emotional or mental difficulties
for which professional help was sought?............. □
□
□
□
□
□
□
□
□
□
If you checked “yes” to any of the above, please note the question number and explain.
Which of the following has the applicant had? (Check each one that applies)
□ Measles
□ Hepatitis A
□ Chicken Pox
□ Hepatitis B
□ German Measles
□ Hepatitis C
□ Mumps
□ Rheumatic Fever
□ TB Test (Date:
, Pos or Neg?
)
Immunizations – Fill in the dates for any of the following immunizations applicant has had.
Immunization
DPT
TD (tetanus/diphtheria)
Tetanus
Polio
German Measles
Date Last Received
Immunization
Mumps
Rubella
Gamma Globulin (Hepatitis)
Chicken Pox
Smallpox
Date Last Received
NOTE: A record of immunizations is for informational purposes. Immunizations are not a required prerequisite for acceptance to or attendance at
camp. If a camper has not been immunized, however, and one of the above-named communicable or contagious diseases is found in camp, he or
she will be subject to the regular quarantine or isolation procedures of the camp and of the community for children who are not immune.
HH2013
Preteen United Youth Camps Health History Form
Page 2 of 4
ADULT APPLICANT: I certify that to the best of my knowledge this health history is correct and complete, that I am in good health and
able to participate in this event/assignment.
Adult applicant signature
Date
PARENT/GUARDIAN AUTHORIZATION:
This health history is correct and complete as far as I know and the person herein described has permission to engage in all camp
activities except as noted. I understand that if any statement in this Health History is false, misleading or incorrect, or the Church is
unable, in its sole judgment, to properly care for or protect my child (due to his/her medical condition), he or she may be sent home at
my expense.
Parent signature
Printed Name
Date
PARENTAL NOTIFICATION POLICY:
United Youth Camps policy is that parents will be contacted 1) anytime the nurse or a physician deems necessary; 2) anytime a
camper is taken to see a physician, dentist or emergency personnel for an accident or illness; 3) when an illness lasts longer than 24
hours.
IMPORTANT – These boxes must be completed for attendance
Permission to Provide Necessary Treatment or Emergency Care:
I hereby give permission to the available medical personnel at the camp to administer prescribed medications and provide routine
health care, including over-the-counter medications, to my child as deemed necessary by the UYC medical staff. In the event of an
accident/illness, I consent to the administration of emergency on-site first aid by trained personnel. If I cannot be reached in an
emergency, I hereby give permission to the camp medical personnel to secure and administer treatment, including hospitalization, for
the person named above. This authorization includes consent to any medical, emergency dental, surgical, chiropractic or hospital
diagnosis, treatment or care to be rendered to or for me/or my child under the general or specific supervision of a qualified physician,
surgeon, chiropractor or dentist. It also includes permission to release any records necessary for supervision, treatment, referral, billing
or insurance purposes and to provide or arrange necessary related transportation. I understand and agree that the foregoing will be at
my expense. This consent shall terminate without further notice on the date when a minor reaches 18 years of age. This completed form
may be photocopied for trips out of camp.
Parent/guardian (or adult camper/staff) signature
Printed Name
Date
If medication for life-threatening conditions is brought to camp (epi pen, inhaler, etc.) I hereby
□ UYC Personnel
□ My Child
(Please check one.)
request that said medication remain with:
I understand that accommodating some medical conditions or disabilities may not be ideal and may differ depending on the activity.
Therefore, if I am accepted, I agree to abide by any restrictions which may be placed on my camp activities that the camp staff feels
are necessary for my comfort or safety or that of my fellow campers or staff.
Camper/Staff signature
Date
Special note about medication:
Please note that if your camper will be bringing ANY medications to camp, including all prescription, over-the-counter and herbal
remedies, the following rules will need to be followed:
1) All medications must be in their original packages. i.e. prescriptions in the prescription bottle, Tylenol in the Tylenol bottle, herbs in
the bottle that they were originally bought in.
2) All medications must be accompanied by written and signed instructions for administration (the prescription on the bottle will be
fine unless doses or times have changed).
3) Any nonprescription bottles must have the camper’s name written on them (prescription bottles must be for that camper).
PLEASE help us to take good care of the precious and wonderful campers that you have entrusted to us! – UYC Medical Staff
HH2013
Preteen United Youth Camps Health History Form
Page 3 of 4
INSURANCE COVERAGE AND RELEASE PAGE
Personal Medical Insurance
The United Church of God is grateful to those who freely give of their time and expertise to assist in the
operation of United Youth Camps (UYC). While we place a significant emphasis on safety at UYC for both staff
and campers, accidents may happen and people may get injured. For this reason, we strongly recommend that
you carry adequate personal medical insurance. We realize that it is not always affordable. However, paying
actual hospital and doctor expenses can easily cost far more. As we review your application, this is an important
factor in determining those most suited to serve at UYC.
***************************
Supplemental Accident Insurance
We realize that your personal insurance may require you to pay a deductible and co-payments, and possibly
other costs. In an effort to help reduce the cost to you personally, the Church has been able to acquire
supplemental accident medical coverage for a nominal cost. Though the Church is unable to provide financial
assistance beyond what is offered through this insurance, we are happy to include all campers as well as staff
volunteers in this coverage, particularly since they are not covered by Workers’ Compensation. The extent
(amount and period) of accident coverage may vary from year to year. If you are accepted as a camper or
approved to serve as a UYC staff member, a copy of the coverage will be supplied upon request.
***************************
Release and Waiver
I have read, fully understand, and agree to comply with all the rules and standards of this preteen camp and its
staff. I understand and agree with its implications and the stated consequences. I also affirm that the
information given in this application is true and complete and that I (or my child) am in good health and able to
participate in the expected activities and routine for this preteen camp. In consideration of being allowed to
participate, I hereby release, indemnify, save and hold harmless and covenant not to sue the United Church of
God, an International Association, its officers, Council of Elders, agents, employees, volunteers and helpers
and any other related entity (hereinafter collectively called the “Church”) from all actions, claims, demands or
suits which are based upon, or result from a medical condition or injuries sustained, arising out of, or in the
course of, participation or attendance at camp. This release, however, shall not apply to claims covered by the
Church’s liability insurance (e.g. for its negligence) , but is applicable to claims not covered by that insurance. It
is strongly recommended that you have your own medical insurance protection since participants are involved
in activities at their own risk.
Signature
Date Signed
Print Name_
Parents’ Signature(s) also Required for Minors:
I/we have read, fully understand and agree to the foregoing statements.
X
Date
X
Father
Date
Mother
A health examination for preteen camp is not required or mandatory, but it is recommended at least once every three years.
HH2013
Preteen United Youth Camps Health History Form
Page 4 of 4
Official UYC Camp Website
uyc.ucg.org
Sponsored by United Church of God, an International Association
Producers of Beyond Today TV and the Good News magazine
UYCTransportationandSignIn/OutForm
Dear Parents, Campers and Staff,
We are excited to see you at camp soon! In order to ensure the safe, orderly and authorized arrival and departure of all campers and
staff to and from camp, we are asking that campers, parents and staff fill out and sign the information and authorization form below, and
send it back with your application no later than the due date.
At each camp’s discretion, this form can additionally be used for signing staff and campers in and out of the facility.
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Arrival & Departure Authorization and Information Form
Name of Camper or Staff:
Last Name
First Name
Arrival Date
Departure Date
 I will drive myself.
 I will drive myself.
 I will be brought to camp by:
 I will be picked up from camp by:
Driver’s name:
Driver’s name
(please print)
(please print)
 If there is any individual who under no circumstances would be
allowed to pick up my child, please list that person(s) here:
I have fully read, understood and intend to comply with the procedures and rules listed on this and cover form. To the best of my
knowledge the above information is complete and accurate. I (if parent of a minor participant) also authorize the above listed person(s)
to transport my child to and/or from camp, and to register and/or sign-out him/her as needed and required.
Signature of Parent or Adult Staff Member
Signature of Minor Staff Member
Date
----------------------------------------------------------------------------------------------------------------------------------------------------------------
Sign In and Out (At Camp)
Sign In Date
Time
:
/
/
am/pm
Signature of Staff Member or Authorized Driver
Sign Out Date
Time
:
/
/
am/pm
Signature of Staff Member or Authorized Driver