This is the registration and forms packet!

This is the CampHERO registration and forms packet!
You have three options for completing your registration and
forms:
IMPORTANT!
Your spot is NOT reserved until
you have completed the
following steps!
1) Register for CampHERO
using the printable registration
form in this packet (page 1-2)
or online at
www.badgerlandcamps.org.
2) Submit your payment.
3) Complete and return all forms
The entire information packet
and payment must be
submitted to secure an open
spot. Incomplete packets will
be considered as pending and
will not be processed until all
paperwork is received.
Open spots will be filled in the
order that completed registration
packets are received. When the
maximum number of registrations
is reached, a waitlist will be
created.
1) Complete the forms in this packet
Sign everything with your electronic signature
Save the document as
"Your Camper's name-CampHERO"
Pay with credit/debit (or mail payment separately)
Email to: program@gsbadgerland.org
2) Complete the forms in this packet
Print the forms and sign manually
Mail forms and payment to:
GSWIBC, ATTN: Program Registrar
2710 Quarry Rd., La Crosse, WI 54601
3) Complete the on-line registration and CampDoc forms
at www.badgerlandcamps.org
(available in February 2014)
Digital Signatures
Your signature is requested numerous times in this document. If you are
signing electronically, you will have to save the document each time you insert
a signature. The first time, save the document as "Camper's NameCampHERO" Each subsequent time, save it under th same title and answer
"yes" to the 'replace existing document question.
The second parent signature is optional
There are a number of ways to insert a digital signature in Adobe Reader.
Right click on the signature block and follow the instructions OR Look for the
"Sign" tab in the upper right corner of the page. If you need further
assistance, check out the video linked below.
Learn how to insert a digital signature by clicking this link.
CampHERO Forms Guide
Complete ALL the forms on the following pages.
Forms Checklist:





Registration Form
Health History Forms.
Code of Conduct
Travel and Media Release Form
Waiver, Release and Indemnification Agreement
Why are there so many forms?
Good question! CampHERO
follows the guidelines of several
organizations, including Girl
Scouts USA & The American
Camping Association, to ensure
camper health and safety. We
collect information that will help
our staff help campers have a
great experience. In addition, our
partners, who allow us the use of
facilities & equipment, require
waivers. We know it’s a-lot, but
it’s necessary!
CampHERO 2014 Registration Form
Online registration is also available at www.badgerlandcamps.org.
A separate registration form must also be completed for each camper
Camper Information – Girl Scout Membership Information
Camper’s Name: _______________________________________Parent/Guardian Phone: (_____) _________________
Address: ___________________________________________ City: _________________ State: ______ Zip: _________
Grade in Fall 2014:_______ Age: ______ Birth date:_________
Member of GS of WI - Badgerland Council?  Yes No
Troop # or Individual: _________
Name of Council, if not Badgerland:_______________________________________
If not currently registered as a Girl Scout, complete this section. Girl Scout membership covers campers with basic insurance
and allows for financial assistance.
I give my daughter, ___________________________, permission to join Girl Scouts of the USA. I understand thatthere are $25
National Registration dues payable for my daughter to join. Please include the $25 GSUSA registration fee with your payment.
CampHERO
Date:___________
Fees:________
Camper Status:
New Resident Camper? Yes No
___Years at CampHERO
Camper's T-shirt Size: check one
Youth Small
Youth Medium
Youth Large
Youth XLarge
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult 2XLarge
ADDITIONAL T-SHIRT ORDER $12 each/$15 2XL and up
Youth Small
Youth Medium
Youth Large
Youth XLarge
Requested Buddy List
You may request up to 3 buddies:
1. _______________________
2. _______________________
3. _______________________
Adult Small
Adult Medium
Adult Large
Adult XLarge
Adult 2XLarge
Parent/Guardian Contact Information
Preferred Communication Contact Method:  E-mail  US Mail
(If camper is an adult please complete Emergency Contact Info only)
My camper is in the custodial care of (check one)  Both Parents  Mother Only Father Only Other___________
Parent/Guardian Name _____________________________ Home Phone (___) _____________ Cell (___)____________
Work or alt. Phone (___)_________________ E-mail Address __________________________________________________
Parent/Guardian Name _____________________________ Home Phone (___) _____________ Cell (___)____________
Work or alt. Phone (___)_________________ E-mail Address __________________________________________________
Emergency Contact (If Parent/Guardian cannot be reached; must have permission to transport the camper):
Name ____________________________ Relationship to Camper ______________ Primary Phone (_____)______________
Alternate Phone (____)_____________________________
Transportation Information:
My family is interested in getting transportation to and from camp.
Yes
Note: transportation is not guaranteed. CampHERO staff will contact you.
No
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Important Note
Electronic Welcome Packet & Camp Forms log-in and registration confirmation will be sent by email to the address listed on
the registration form above. Confirmation will come from email address noreply@uapps.net.
Method of Payment
Payment Summary
*Check/Cash/Credit Card for full payment is expected by May 1st or at time of
registration after May 1st. If using Badgerland Bucks or Trip Certificates: submit
with this form or if submitting separately, include a written explanation
including the name of the camper, program, and dates attending.
Total Camp Program Fees:
GSUSA Membership:
($25 dues for new or renewing members)
+
ADDITIONAL CampHERO t-shirt(s):
+
Subtotal:
=
$12 each. $15 size 2XL and over.
List sizes on page 1
Badgerland Bucks:
(Certificates Enclosed)
$ 0.00
-
Trip Certificates: (Certificates Enclosed)
-
Payment Required**
=
Camperships available.
See www.CampHERO4girls.org for more information.
$ 0.00
 Enclosed is a check for $_________ payable to GSWIBC.
Charge my: VISA  MC AMEX DISC
Please check one:  Payment in full
 $100 Registration Deposit (program fee $200+)
 $50 Registration Deposit (program fee $100-199)
 Plus $______ payment toward my account balance
 Please accept $_________ additional as my donation
toward camperships for girls to attend camp.
Card Number: ____________________________________
V-Code_________Expiration Date: ____________________
Billing Address:____________________________________
_________________________________________________
Print name as it appears on card: _____________________
Cardholder’s Signature: _____________________________
________ (Parent/Guardian Initial)
Girl Scouts of Wisconsin – Badgerland Council Refund Policy
The registration deposit is non-refundable. The balance of the camp fees will be refunded only if: (1) A written request is received from the
parent/guardian at least two weeks prior to the camp program session. (2) Refunds may be made for illness or critical family emergency provided a
cancellation call was made and a message left prior to the session starting. In case of illness, a written refund request with a statement from the
attending physician must be received within one week after the camp program session. (3) Other requests for refunds due to extraordinary
circumstances will be considered at the discretion of the CEO or designee. (4) If we are unable to place your camper in any of her choices, due to the
program being at capacity or due to cancellation by GSWIBC personnel for extenuating circumstances, the total amount paid, including deposit will be
refunded. PLEASE NOTE: Campers who leave camp early due to homesickness, parental request, or behavior contract violations are not eligible for
refunds.
Parent/Guardian Consent
I have read the information provided in the camp brochure and give my permission for my child to attend Girl Scout camp. I give permission for my
camper to participate in all activities unless otherwise indicated on her health information. Activities may include swimming, horseback riding, out-ofcamp activities, and may include overnights as part of the camp experience.
I understand that there are inherent risks in program activities and my camper agrees to follow the directions and safety rules of the instructor/guides
and cooperate with them. Moreover, I understand that the instructors have the authority to discontinue participation in the program if my camper does
not follow the program safety instructions and policies and/or endangers the group due to the camper’s behavior. I understand that the use of illegal
substances, tobacco, and alcohol are prohibited and if used or possessed would result in my camper’s immediate departure from the program to home
at my responsibility and expense. I understand that the council is not responsible for lost items. I understand that on camp arrival day, the camp
personnel have the right to refuse to admit a girl to the camp who does not meet acceptable health conditions (e.g. temperature, contagious disease,
lice). I authorize the director to obtain medical care for my child in the case of a medical emergency.
 I give my permission for my camper to be photographed/videotaped and allow GSWIBC and GSUSA to release said media for Girl Scout and camp
publicity purposes. This includes print and web marketing/publications.
 I do not give my permission for my camper to be photographed/videotaped and allow GSWIBC and GSUSA to release said media for Girl Scout and
camp publicity purposes. This includes print and web marketing/publications.
Parent/Guardian Signature (Required) _____________________________________________________________ Date ___________________________
Parent/Guardian Name (Please Print) _____________________________________________________________
Mail Registration Form and Payment to: GSWIBC, ATTN: Program Registrar, 2710 Quarry Rd., La Crosse, WI 54601
If paying by credit card, you can submit by fax to 608.784.3613 or e-mail to program@gsbadgerland.org.
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Screening Record for CAMP USE ONLY:
Date screened:
Medication(s) received
Yes No
Recent exposure to
Health Form up to date:
YesNo
communicable disease?
Yes No Camp Health Personnel Signature
Evidence of illness or injury?
YesNo
Notes
HEALTH HISTORY FORM This form is used by all campers (child & adult) attending a DAY CAMP program. Make a photocopy for your records.
BRING ALL MEDICATIONS TO BE ADMINISTERED AT CAMP, IN ORIGINAL CONTAINERS, PACKED IN A ZIP-LOCK BAG AND
LABELED WITH NAME.
CAMPER FULL NAME
DATE OF BIRTH
AGE
HOME ADDRESS
CITY
STATE
ZIP CODE
PARENT/GUARDIAN # 1 FULL NAME
HOME ADDRESS
Same as above OR complete below
CITY
CAMPER’S CELL PHONE
NONE
HOME PHONE
CELL PHONE
STATE
ZIP CODE
BUSINESS PHONE OR 2ND CELL
PARENT/GUARDIAN # 2 FULL NAME
HOME PHONE
HOME ADDRESS
Same as above OR complete below
CELL PHONE
CITY
STATE
ZIP CODE
BUSINESS PHONE OR 2ND CELL
IF WE CAN NOT REACH PARENTS WHO SHOULD WE CONTACT IN AN EMERGENCY
NAME
RELATIONSHIP
AREA CODE + PHONE
NAME
AREA CODE + PHONE
RELATIONSHIP
FAMILY PHYSICIAN
AREA CODE + PHONE
INSURANCE COMPANY NAME
AREA CODE + PHONE
NAME OF POLICY HOLDER
POLICY/GROUP NUMBER
PARENT LOCATION DURING CAMPER STAY:
HOME
OUT OF TOWN- Please bring details to check in day
PARENT/GUARDIAN AUTHORIZATION
This health history is complete and accurate. I know no reason(s), other than the information indicated on this form why this camper, should not
participate in prescribed activities except as noted
Authorization of Treatment: I give permission to the appropriate personnel to care for minor illness/injuries, using over-the counter
medications/procedures as authorized in the standard operating guidelines. I give permission to camp personnel to administer medications I have listed
on the health history and/or physician prescribed on the physical exam. I will send medications in original containers. I hereby give permission to the
medical personnel selected by the camp director to order x-rays, routine lab tests, treatment; to release any records necessary for insurance purposes. In
the event that I cannot be reached in an emergency, I hereby give permission to the physician or other appropriate medical personnel selected by the
camp director or health supervisor to secure and administer treatment, including hospitalization for the person named above; and to provide or arrange
necessary related transportation for me/or my child. This complete form may be photocopied for out of camp trips.
Parent/Guardian Signature
Parent/Guardian Signature
Health Information Provided by Parent/Guardian
Camper Name:
ALLERGIES List all known. Attach additional sheets if needed.
Medication Allergies:
Check here if
NONE
Describe reaction(s) & management of reaction(s)
Food Allergies:
Describe reaction(s) & management of reaction(s)
Other Allergies:
Describe reaction(s) & management of reaction(s)
DIET/NUTRITION Check all that apply:
This camper eats a regular diet
This camper has special food needs (PLEASE DESCRIBE ):
This camper eats a regular vegetarian diet
General Questions (check all that apply and explain below)
1 Ear Infection
6 Diabetes
11 Menstrual Cramps
16 Hearing Impairment
2 Heart Defect/Disease
7 Asthma/Breathing
12 Motion Sickness
17 Sickle Cell Trait or Disease
3 Bleeding/Clotting Disorder
8 Seizures
13 Nosebleeds
18 Fainting
4 Hypertension
9 Bed Wetting
14 Sleep Disorders
19 Wears Glasses or Contacts
5 Musculoskeletal Disorders
10 Constipation
15 Emotional Disturbances
20 Other (specifiy)
Please explain any “yes” answers, noting the number of the question (attach additional sheets if needed)
Which of the following has the camper had? Check all that apply
Measles
Chicken Pox
Mumps
Hepatitis
Immunizations Check ONE:
My daughter/I have been fully immunized and immunizations are all up-to-date.
My daughter/I have NOT been fully immunized or immunizations are NOT up-to-date If you check this option, you must sign the statement below:
I understand and accept the risks to my child from not being fully immunized. Signature of custodial parent/guardian:
PERMISSION FOR OVER THE COUNTER MEDICATIONS
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.
Please check which over the counter medications we have consent to administer to your child on an as needed basis at the discretion of the Health
Supervisor.
NONE
Acetaminophen (Tylenol)
Lice shampoo
Antibiotic cream
Aloe
Ibuprofen (Advil, Motrin)
Antihistamine/allergy medicine
Calamine lotion
Hydrocortisone Cream
Antacids
Bismuth subsalicylate/Pepto-Bismol
Kaopectate or Imodium AD
Cough drops
Cough suppressant
Include this section only if medications are being brought to camp!
MEDICATIONS CURRENTLY PRESCRIBED/BEING TAKENPlease list ALL medications (including over-the-counter or non-prescription drugs) taken routinely. “Medication” is any substance a person takes to maintain
and/or improve their health. This includes vitamins & natural remedies. Bring enough medication to last the entire length of stay (both prescribed & over the
counter). Keep medication in the original packaging/bottle that identifies the prescribing physician (if prescription), name of the camper, name of the
medication, dosage, & frequency of administration. Label all over-the-counter medications with camper’s name.
This person takes medications as follows:
Medication/
Reason prescribed, taken
Vitamin Name
or circumstances in which
medication is to be given
Dose & Route
Frequency/ Number
of times per day
taken
Time(s) to be administered. Check all that apply.
Note: meal times are general. If medication
needs to be administered at a specific time,
please indicate.
Breakfast
Bedtime
Specific time:
Breakfast
Bedtime
Specific time: :
Breakfast
Bedtime
Specific time: :
Breakfast
Bedtime
Specific time:
Lunch
Dinner
As needed
a.m.
p.m.
Lunch
Dinner
As needed
p.m.
a.m.
Lunch
Dinner
As needed
a.m.
p.m.
Lunch
Dinner
As needed
a.m.
p.m.
Code of Conduct
Participant and Parent/Guardian Expectations
Below is the Code of Conduct Participant Behavior Contract for you and your camper to
read and sign. The following is an explanation of our expectations of you as the
parent/guardian.
Campers that violate the Behavior Contract will be sent home. Upon a violation of the Behavior Contract, the Incident Commander will call
the parent/guardian(s) listed on the contract. The parent/guardian will be informed of the violation at camp and will be asked to pick up the
camper. If the parent/guardian cannot come to camp, it remains the parent/guardian’s responsibility to make arrangements for someone
else to pick up the camper, as soon as possible. In those instances, the parent/guardian must also call the Incident Commander to inform
her of who will be picking up the camper.
If the parent/guardian refuses to arrange pick up, the Incident Commander or designee, will contact the emergency contact person listed on
the camper’s health form, to make arrangements. If the Incident Commander or designee cannot locate the emergency contact person or
the emergency contact person also refuses to pick up the camper, the parent/guardian will be called again.
If no one agrees to pick-up the camper after these steps have been taken the Incident Commander or designee will call County Social
Services to arrange housing until the parent/guardian arrives.
Participant Behavior Agreement
I understand that my attitude and behavior are critical to my success and to the success at camp this summer. Therefore, for the good of all,
I agree to abide by the following:
1.
2.
3.
4.
5.
6.
7.
8.
I will try to be sensitive to the needs of each camper by performing my assigned duties, including but not limited to: unit kapers, allcamp kapers, cleanup, participating in all-camp activities, etc.
I will respect the places and the people with whom I come in contact.
I understand that the use of alcohol, tobacco, profane and/or threatening language, or drugs will not be tolerated, and that usage
during camp will result in expulsion from my camp program.
I will be responsible for my personal belongings and equipment and will not hold CampHERO /Girl Scouts of Wisconsin
Badgerland Council, Inc., or any other outsider responsible for the loss or damage due to my negligence or neglect.
I will treat equipment provided by CampHERO /Girl Scouts of Wisconsin Badgerland Council, Inc. or any other person with
care.
I will use safety equipment furnished by CampHERO /Girl Scouts of Wisconsin Badgerland Council, Inc. for my own safety.
I will treat other campers and staff with respect and courtesy.
I understand that if I do not abide by the guidelines listed above, the camp director will notify my parents/guardians, and I will be
sent home. I also understand that if I am sent home early due to misconduct, I will not receive a refund.
I have read, understand and agree with the above responsibilities of my daughter. I have read, understand and agree to fulfill
my responsibilities as a parent/guardian.
Parent/Guardian Signature
Parent/Guardian Signature
Camper Travel and Media Release Form
In order to assure the safe release of all campers to their legal parent/guardian, or other
person as designated by the parent, this form must be provided to the CampHERO
personnel when the camper is dropped off. No child will be released without this form. See
your CampHERO Welcome Packet for more information about this form.
Camper Name:
Camper Home Phone:
Camper Cell Phone:
City:
Address:
State:
Zip:
Media Consent (choose one)
I give my permission for my camper to be photographed/videotaped and allow CampHERO, GSWIBC and GSUSA to release said
media for Girl Scout and Camp publicity purposes. This includes print and web marketing/publications.
I do not give my permission for my camper to be photographed/videotaped and allow CampHERO, GSWIBC and GSUSA
to release said media for Girl Scout and Camp publicity purposes. This includes print and web marketing/publications.
Please note: If you do not give permission, you camper will not be allowed to appear in ANY pictures including those taken by other
campers. They will be required to wear name tags that state "NO PICTURES" at all times.
Travel Information
Describe how your daughter is traveling to/from camp (ex: car with family, air-unaccompanied minor):
I am requesting an earlier or later drop off or pick up time. (Note: we can not accomodate all requests) Explain:
List the person(s) that are authorized to pick up your camper (including parents).
Campers will ONLY BE RELEASED TO THE PERSON(S) LISTED HERE!
1) Full Name:
Identification/Driver’s License Number:
Full Address:
Relationship to Camper:
2) Full Name:
Phone:
Identification/Driver’s License Number:
Full Address:
Relationship to Camper:
Phone:
By signing this form I affirm that those persons listed are aware that they will be required to show photo
identification when they pick up my child, INCLUDING PARENTS! No child will be released without this form
being completed.
CampHERO /GSWIBC Staff Use Only
Date of Release_____________________________________________Signature____________________________________________
The Adult to whom the camper is released:
Print Name ________________________________________________ Identification #______________________________________
Staff Signature___________________________________________________
Date___________________
WAIVER, RELEASE, AND
INDEMNIFICATION AGREEMENT
I,
parent of
1.
and/or
(camper) in consideration of being permitted to participate in CampHERO, hereby acknowledge and agree as follows:
I understand the nature of the activities I/my child may perform while involved in field training activities, known as CampHERO, requires mental judgment and a
degree of physical fitness, agility, and dexterity, and that this may include exercise which requires physical fitness, strength and stamina in varying environmental
conditions, including confined spaces, elevated temperatures, smoke, and falling/flying debris. This may involve wearing of special protective gear including a SelfContained Breathing Apparatus (SCBA) and the use of specialized equipment which may be heavy and cumbersome. While there will be trained individuals assisting
at the program, I will participate in events with others; these fellow participants will be civilians with no firefighting or EMS skills.
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2.
I understand that field training involves the risk of injury or death, and I voluntarily assume these risks. I understand and agree that it remains my/my child’s decision
to participate in all or any part of the program; and I further understand and agree that I/my chile may discontinue active participation at any time and simply
participate as an observer.
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HEALTH INSURANCE
3.
I understand that The City of Madison and Madison College will not provide medical or health insurance coverage to me during any aspect of my/my child’s
participation in the program/activity described herein. I hereby represent and warrant that I am/we are and will be covered throughout the activity by a policy of
accident and health insurance that provides coverage for injuries I/my child may sustain in the course of my participation in the program/activity. I understand I may
be required to show proof of insurance coverage prior to my/my child’s participation in the program/activity.
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INDEMNIFICATION
4.
I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby agree to indemnify, defend and hold harmless the City of
Madison and Madison College and each of the foregoing entities’ employees, agents, and representatives, from any and all liability whatsoever for any and all
damages, losses, or injuries (including death) sustained to person or property or both, including but not limited to any claims, demands, actions, causes of action,
judgments, expenses and costs, including attorneys fees, which arise out of, result from, occur during, or are connected in any manner with my/my child’s intentional
and/or negligent conduct during my participation in the program/activity or that arise out of or are in any way connected to my/my child’s participation in CampHERO.
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RELEASE OF LIABILITY
5.
To the extent authorized by law, I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby release and forever discharge
The City of Madison and Madison College, each of the foregoing entities’ employees, agents, and representatives, from any and all liability, loss, damage or
expense, including attorneys fees, that they or any of them incur or sustain as a result of any claims, demands, actions, causes of action, damages, judgments, costs
or expenses, including attorneys fees, which arise out of, occur during, or are in any way connected with my intentional and/or negligent conduct during my/my
child’s participation in the program, or that arise out of or are in any way connected to my participation in CampHERO.
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6.
To the extent that I, individually, or my heirs, successors, assigns, or personal representatives bring a claim of any kind whatsoever against The City of Madison and
Madison College, each of the foregoing entities’ employees, agents, and representatives, I agree that this Waiver, Release and Indemnification Agreement is to be
construed under the laws of the State of Wisconsin and that if any portion hereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal force
and effect. In signing this document, I hereby acknowledge that I have read this entire document, that I understand its terms, that by signing it I am giving up
substantial legal rights I might otherwise have, and that I have signed it knowingly and voluntarily.
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7.
I understand and agree that any and all disputes arising out of or in connection with my participation in CampHERO shall be litigated only in the Dane County, and in
no other court, and I hereby consent to the jurisdiction of this court.
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8.
I certify that I am a member of the agency or employee listed on my application, if applicable, and that the agency or employer listed is aware of and supports my
participation in this program.
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9.
I certify the information provided on this Waiver, Release and Indemnification Agreement is true and accurate.
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10.
I understand and agree that I am responsible for attending all safety training required by the class in which I am enrolled. I understand that I must abide by all the
rules and policies set forth by The City of Madison and Madison College. I understand that the rules and guidelines of CampHERO are intended to protect me and
other participants from harm, to protect property from damage, and to make my learning experience and the learning experience of other participants enjoyable. I
understand that my failure to abide by the rules and policies may result in my being denied admission to the event or may result in my being dismissed from the
event.
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PHOTOGRAPHS/VIDEO
11.
I hereby grant full permission to Madison College and The City of Madison, to prepare, use, reproduce, publish, distribute and exhibit my name, picture, portrait,
likeness or voice, or any or all of them in or in connection with the production of web sites, still photography, motion picture film, television tape, film or sound track
recording, scientific publication for informational or any other professional purpose deemed by Madison College or The City of Madison necessary in the interest of
the college’s/city’s mission.
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12.
I hereby waive all rights of privacy or compensation for me, which I may have in connection with the use of my name, picture, portrait, likeness of voice, or any or all
of them, in or in connection with said web sites, still photography, motion picture film, television tape, film or sound track recording and nay use to which the same or
any material therein may be put, applied or adapted by Madison College. This consent and waiver will not be made the basis of a future claim of any kind against
Madison College and nay of its agencies, including defamation and invasion of privacy claims.
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Participant Name (Printed):
Parent/Guardian Signature
Parent/Guardian Signature