Camp Chimaqua Camper Application

Facebook

This field is for validation purposes and should be left unchanged.

This field is hidden when viewing the form

Application received

CAMPER INFORMATION

This field is hidden when viewing the form

Date

Camper's name*

First Middle Last

Home address*

Street Address Address Line 2 City State ZIP Code

Date of birth*

Age*

Sex*

Male

Female

Current school grade*

School attending*

Parent/Guardian's name*

First Last

Day phone*

Evening phone*

Email address*

How did you hear about Camp Chimaqua?*

Has your child ever spent the night away from home?*

Yes

No

Have you talked to your child about attending Camp Chimaqua?*

Yes

No

What, if any, concerns do you have about your child going to camp?

Child's t-shirt size*

CAMPER EMERGENCY CONTACT INFORMATION

In case of emergency and parent/guardian cannot be reached, contact:

Emergency Contact #1*

First Name Last Name

Phone*

Emergency Contact #2*

First Name Last Name

Phone*

AUTHORIZATION FOR RELEASE

For your child’s safety, Camp Chimaqua staff and volunteers have permission, before releasing your child, to ask anyone to present a photo ID (i.e. driver’s license). We will not release your child unless proper identification is given. Please list persons (including yourself) authorized to pick up your child.

Authorized Individuals*

Click to add individuals.

First & Last Name

Phone

Relationship to Child

CAMPER INTERESTS

Has your child ever:*

Attended day camp?

Attended overnight camp?

Does your child enjoy:*

Music?

Outdoor activities?

Arts and crafts?

Creative writing?

Reading?

Sports/physical activity?

Please list the sport(s)/activities*

What is your child's favorite color?*

What is your child's favorite TV show/movie?*

What is your child's favorite sports team?*

What is your child's favorite animal?*

Please list other things your child enjoys doing*

(hobbies, interests, etc.)

Is there anything we should know to better accommodate your child?

MEDICATION INFORMATION

Will your child be taking medication at camp?*

Yes

No

Please specify below*

Medication/Dosage

For what?

Time(s) to be given

Method of administration (to be taken with water, milk, food, etc.)

Click to add medications.

List any reasons for not giving medication at the prescribed time*

(vomiting, fever, drowsiness, convulsions)

Is there any additional information that the Camp Chimaqua staff should know concerning your child?*

PARENT/LEGAL GUARDIAN CONSENT FOR PARTICIPATION

Hospice & Community Care considers the information you provide regarding your child to be confidential. It will only be made available, to the extent necessary to appropriate camp staff, volunteers, and Pathways Center for Grief & Loss staff who will be working with your child.

I understand that the registration fee is non-refundable after May 8, 2025.

I understand and agree that if my child appears ill prior to attending camp, I will not send my child to camp.

I confirm that all information provided is, to the best of my knowledge, accurate and complete.

I understand that, in the event of a medical emergency I will be immediately contacted. Hospice & Community Care on-site medical staff (registered nurse, CPR certified staff and/or physician) will initiate immediate medical, and if necessary, life sustaining measures and will contact, if needed, emergency medical personnel for assistance.

I further understand that my preferred physician/medical facility will be contacted and utilized whenever possible. If I am unable to be reached and medical circumstances require immediate transport for care, this will be initiated, and emergency medical personnel will provide for the immediate needs of my child and determine the transport location.

Preferred physician name*

Physician phone*

Hospital*

Medical insurance*

Medical insurance phone*

Policy holder's name*

First Last

Identification or Policy/Group#*

Employer*

I hereby release and discharge Choices Healthcare, it’s employees or volunteers from any legal responsibility and/or liability for any personal injuries or illnesses, either physical or emotional; or injury to property, real or personal, whether that injury is due to negligence or any other fault, which may occur while my child attends Camp Chimaqua. I have read the information on the Pathways Center for Grief & Loss. I have received Choices Healthcare’s Notice of Privacy Practices. I understand the Camp Chimaqua program provided by the Pathways Center for Grief & Loss, have had the opportunity to ask questions and have received acceptable and understandable answers. I understand the services that are available through the Pathways Center for Grief & Loss, realize its limitations and benefits, and voluntarily choose to participate in services for myself and my child.

Parent/Guardian Signature*

Typed Parent/Guardian Name*

Date*

CAMP CHIMAQUA RELEASE FORM – For Minors

I hereby assign and release Choices Healthcare all rights to the electronic image/film/ photography/DVD/sound recordings and written statements made by me, my child (if under 18 years old), and/or Choices Healthcare, and I hereby authorize the use of same by Choices Healthcare, and those acting with its permission, for the purpose of education, illustration, publications, social media or broadcast in connection with the work of Choices Healthcare. I agree to receive emails of the above items for my personal memories.

I hereby assign and release Choices Healthcare all rights to utilize group electronic image/film/photography/DVD/sound recordings and written statements made by me, my child, and/or Choices Healthcare, and I hereby authorize the use of same by Choices Healthcare, and those acting with its permission, for the purpose of education, illustration, publications, social media or broadcast in connection with the work of Choices Healthcare. I understand these items could be shared with other participants families. I agree not to share any items sent to me via email on social media to protect the privacy of other participants.

Any disclosure of other patient-related information by Choices Healthcare, whether written or verbal, requires separate authorization.

I understand that I have the right to request cessation of the production of the recordings, films, or other images by submitting a written request.

I certify that I am over 18 years old, or if not, that a parent/guardian has signed below.

I have read the foregoing release and authorization before affixing my signature and I warrant that I fully understand the contents thereof.

Release Form Consent*

I DO consent to Choices Healthcare utilizing electronic image/film/ photography/DVD/sound recordings and written statements made by me or my child.

I DO NOT consent to Choices Healthcare utilizing electronic image/film/ photography/DVD/sound recordings and written statements made by me or my child.

I would prefer to discuss the release form at the camp assessment in order to make my final decision.

Parent/Guardian Signature*

Typed Parent/Guardian Name*

Date*

CAMPER INFORMATION

CAMPER EMERGENCY CONTACT INFORMATION

AUTHORIZATION FOR RELEASE

BEREAVEMENT HISTORY

CAMPER INTERESTS

SPECIAL DIET REQUESTS FOR GRETNA GLEN

CAMPER HEALTH HISTORY INFORMATION

MEDICATION INFORMATION

PERMISSION TO ADMINISTER MEDICATIONS

BEE STING HISTORY AND EMERGENCY EPIPEN INFORMATION

PARENT/LEGAL GUARDIAN CONSENT FOR PARTICIPATION

CAMP CHIMAQUA RELEASE FORM – For Minors