R. B. Stall High School Camp LEAD Camper/Participant Application

Name: ______Preferred Name: ______

Email Address, if any: ______

Current School: ______Grade level for the 2016-2017: ______

Parent/Guardian Information:

Name: ______Email: ______

Home Phone: ______Work Phone: ______Cell:______

Medications: Please understand that our staff is not allowed to dispense medications of any kind. If your child has medication that he/she has to take or have on site for their safety, we ask that you have someone to come to administer that medication to the child or the child will have to administer it themselves.

Storage of Medications:

1. Your child may keep their medication in their backpack for easy access. Check here and initial here for option one _____.

2. We can put the medication in an unlocked, but secure location where the child can have access when necessary. Check here and initial here for option two. ____

Allergies and Other Medical Issues: Please make us aware of any food allergies or other allergies which may affect my child’s participation in the camp as a junior counselor. Please list below any allergies or other medical issues that we need to be made aware of. If none, please initial here. ____

Transportation: You will need to provide your own transportation to and from the school the week of the camp. Please indicate how you will arrive and depart. ______

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Emergency Contact Name:______Phone: ______

Discipline Policy: While we anticipate no discipline issues from this group, please understand that we will follow a protocol that includes a warning, parent meeting, and possible removal from the group if the issue is severe enough in either degree or persistence.

Picture Release: Camp LEAD and RB Stall HS Student Council may use my child’s picture in upcoming advertisements for future camps both in print and online. ______(initial here if true)

Parental Permission: I give my child permission to participate and lead the activities of our Camp LEAD. That permission includes taking part in all camp activities, including field trips. In consideration for my child’s entry, I hereby for myself, my child, my heirs, executor and administrators, waive and release any and all rights and claims to

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Name date