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2016 CWES Camp Registration and Health Form
Camper Name:
Birthdate:_____ / _____/ _____
Phone Number:
Age on 1st day of camp:______
Home Address:______________________________________
Sex:  Male  Female
Street
__________________________________________________________________________________
City
State
Zip
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name:
Relationship to
camper:
Check the name of the camp
you are registering for:
-------------------------------------- Everything Under the Sun
(June)
with horseback riding
 Outdoor Skills
 Sky’s the Limit
 Earth Explorers
 Outdoor Odyssey
 Everything Under the Sun
(July)
--------------------------------------Backpacking with a Splash
Devil’s Lake Mini-Adventure
Trip
 Rock Island Adventure Trip
--------------------------------------Day Camp-August 2
Day Camp-August 3
Day Camp-August 10
Day Camp-August 11
Address:
Phone number: Home:
Work:
Email address:
Fax:
SECONDARY EMERGENCY CONTACT
Name:
Relationship to camper:
Phone number: Home:
Are you picking up and dropping off your camper at CWES?
Work:
Dropping off?  Yes
Picking up?
 Yes
 No
 No
If not, who has permission to transport your camper:
Name:_________________________________________________ Phone Number: ______________________________
For campers over 16: Will the participant be driving a vehicle to camp?
 Yes  No
Does your camper have a friend coming that they would like to share a cabin with?  Yes  No
If so, please list their name/s here:
PAYMENT INFORMATION
How are you paying the camp fees?
 Check
 Money Order
 MasterCard
 VISA
Amount of payment___________________
If faxing your registration form and using a credit card for payment, please send to CWES at 715-346-2493.
Name as it appears on card: __________________________________ Expiration date: __________________________
Card number: _____________________________________________ Security code (3 digits on back):______________
Signature of cardholder: _____________________________________________ Date: ___________________________
If paying by credit card and don’t have a fax machine please call Sheri at 715-346-2704.
Required at time of registration:
Minimum $100 non-refundable deposit for overnight camps (full payment encouraged)
$45 full payment for day camps
 Scholarship from:
Name of sponsor:
in Amt of $
Please return registration/authorization/health form along with a $100 non-refundable deposit to:
CWES Summer Adventure
10186 County Road MM
Amherst Junction, WI 54407
Questions? Call CWES at 715-346-2937
While your son, daughter, or ward is at camp, it is our policy to secure your consent for all of the following:
Agreement for Assumption of Risk, Indemnification, Release, and Consent for Emergency Treatment
I,
(print name), age
, desire to allow my child/ward
(print name) to participate voluntarily in Central Wisconsin Environmental Station (CWES) camps and/or programs at the University
of Wisconsin–Stevens Point.
I UNDERSTAND THAT I AM BEING ASKED TO READ EACH OF THE FOLLOWING PARAGRAPHS CAREFULLY. I UNDERSTAND
THAT IF I WISH TO DISCUSS ANY OF THE TERMS CONTAINED IN THIS AGREEMENT, I MAY CONTACT Scott Johnson, CWES
Director at 715-346-2707 or Jeff Karcher, UWSP Director of Safety & Loss Control at 715-346-3901.
CONSENT FOR EMERGENCY TREATMENT
While the Central Wisconsin Environmental Station (CWES) has operated with an excellent safety and health record since its
opening in 1975, illness and injuries sometimes occur. Should a medical emergency occur, we will notify you immediately. If
we are unable to reach you and your child needs medical attention, your child will be transported to the Aspirus Clinic in Plover
Wisconsin or Saint Michael’s Hospital Emergency Room in Stevens Point and treated by the physician on duty.
I authorize the University of Wisconsin-Stevens Point and its designated representatives to consent, on my behalf, to any
emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. In the event that I
cannot be reached, I give permission to the physician selected by the Central Wisconsin Environmental Station to secure and
administer proper medical treatment, hospitalize, order injection, anesthesia, or surgery for the participant. I agree to be
responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.
Guardian Signature
Date
ASSUMPTION OF RISKS
I understand that physical activity related to CWES camps and programs, by their very nature, carry certain inherent risks that
cannot be completely eliminated regardless of the care taken to avoid injuries. Activities may include hiking, climbing, fishing,
swimming, game playing, boating/canoeing, campfire gathering, archery, horseback riding, ropes course, fieldtrips and other
camping activities (refer to your specific camp description for details). The specific risks vary from one activity to another, but
in each activity the risks may range from: 1) minor injuries such as scratches, bruises, and sprains to 2) major injuries such as
fractures, internal injuries, joint or back injuries, heart attacks, and concussions to 3) catastrophic injuries including paralysis
and death. I understand that the University has advised me to seek the advice of a physician before allowing participation by
my child/ward. I understand that I have been advised to have health and accident insurance in effect and that no such coverage
is provided for my child or ward by the University or the State of Wisconsin. I know, understand, and appreciate the risks
that are inherent in the above-listed programs and activities. I hereby assert that my participation is voluntary and that
I knowingly assume all such risks.
Guardian Signature
Date
HOLD HARMLESS, INDEMNITY AND RELEASE
In consideration of permission for me to voluntarily participate in CWES camps and/or programs, today and on all future dates, I,
for myself, child/ward my heirs, personal representatives or assigns, agree to defend, hold harmless, indemnify and release the
Board of Regents of the University of Wisconsin System, the University of Wisconsin-Stevens Point, and their officers, employees,
agents, and volunteers, from and against any and all claims, demands, actions, or causes of action of any sort on account of damage
to personal property, or personal injury, or death which may result from my participation in the above-listed program. This release
includes claims based on the negligence of the Board of Regents of the University of Wisconsin System, the University of
Wisconsin-Stevens Point, and their officers, employees, agents, and volunteers, but expressly does not include claims based on
their reckless and intentional misconduct or gross negligence. I understand that by agreeing to this clause I am releasing
claims and giving up substantial rights, including my right to sue. I also agree to reimburse the Central Wisconsin
Environmental Station for any expense incurred for any medical treatment received by my child/ward while participating. In the
event of major medical treatment, Saint Michael’s Hospital or other medical facility will contact you regarding payment.
Guardian Signature
Date
PHOTOGRAPHIC/VIDEO RELEASE
I understand that the University of Wisconsin-Stevens Point and the Central Wisconsin Environmental Station may take
photographs and/or videos of camp participants and activities. I agree that the University of Wisconsin-Stevens Point shall be the
owner and may use such photos and/or videos relating to the promotion of future camps and programs. I relinquish all rights that
I may claim in relation to the use of said photographs and/or videos.
Guardian Signature
Date
CAMPER HEALTH HISTORY
Camper Name:_____________________________ Birthdate:__________ Age:______  Male  Female
To the Parent(s) or Legal Guardian - Consent for medication administration and treatment:
Because your son or daughter will be under 18 while at the University of Wisconsin–Stevens Point, it is camp policy to
secure your consent for medical care and distribution of prescription and over-the-counter medication. All medications
will be stored in the Health Lodge except those required for life threatening conditions such as bee sting kits,
inhalers, insulin, etc.
***REQUIRED*** Date of your camper’s last Tetanus shot (month/year):
/
All prescription medication must be in the original medicine bottle (see picture at right) and labeled with the camper’s
name, doctor’s name, medication name, dosage, prescription number, date prescribed, and instructions. You must
complete the form below.
 No medication(s) has been brought to camp.
 I want the medication or medical device administered by the designated camp staff.
However, a limited amount of medication for life-threatening conditions may be carried by
my son/daughter/ward (i.e. bee sting kit, inhaler, insulin syringe).
Medications camper will be taking at camp (attach additional pages if needed):
Name of Medication
Reason
Dosage (mg)
Times of day given Prescribing physician and phone number
***Some parents/guardians believe that a week of camp is a good time for their camper to take a break from or try out
new ADD/ADHD/other medications. As camp is a new environment with many changes from the camper’s normal
environment, we strongly request that you maintain your child’s regular medication routine as we have witnessed negative
impacts from these types of changes in the past.
Do you grant CWES permission to administer over-the-counter medications to your son, daughter or ward?:  Yes  No
If yes, please list any over-the-counter medications that you do NOT want CWES to administer:  None
Are your camper’s school required immunizations up to date?  Yes  No
Health Conditions (check all that apply to the camper and explain below, including severity)
 Sleepwalking
 Bed-wetting
 Athlete’s foot
 Warts
 Eating Disorder
 Diarrhea/Constipation
 Abnormal Menstruation
 Homesickness
 Does NOT swim (describe)
 Nightmares
 Exercise Induced Difficulties
 Frequent Ear Infections
 Heart Defect/Disease
 High Blood Pressure
 Diabetes
 Frequent Headaches
 Indigestion
 Sinus Trouble
 Frequent Nose Bleeds
 Bleeding/Clotting Disorder
 Fainting/Dizziness
 Emotional/Behavioral Disorder
 Skin Problems
 Bone/Joint Problems
 Head/Neck/Back Injuries
 Epilepsy/Convulsions/Seizures
 Visual Impairment/Glasses
 Hearing Impairment/Aids
 Speech Impairment
 Learning Disability
 ADD or ADHD
 Cognitive Disability
 Chronic Illness/Condition
 Cerebral Palsy/Motor
 Picky Eater
 Vegetarian
 Vegan
 Gluten Free
 Allergies
 Asthma
 Contagious Disease(s)-List
 Other
Camper’s Swimming Ability:  Poor  Fair  Good
Give details including triggers, signs/symptoms, care procedures and when to call parent and/or 911 for any conditions
checked above:  None
ALLERGIES: Please list and describe any participant allergies to medications, food, insects, animals, plants, etc…
Medications:  None
Foods:  None
Insects/Animals/Plants/etc.  None
RESTRICTIONS: List and describe any restrictions, limitations, or other conditions including: recent
injury/illness/infection, Dietary, Health Conditions (physical, behavioral, emotional, mental), Impairments, Other
Illnesses, Major Surgeries, Special Needs, Family Conditions and indicate if there are any adaptations that can be made:
 None
Name of Insurance Co.:
Insurance Co. Phone #
Family Physician and/or medical facility:
Policy #:
Holder:
Phone Number:
I hereby state that the information I have provided is accurate and complete. I understand that it is my
responsibility to provide any changes/updates to CWES. I further understand that my failure to provide
accurate, complete, and updated information may jeopardize participation in this program. If participant has
NOT been fully immunized – I understand and accept the risks from not being fully immunized.
Guardian Signature:
Date:
CWES CAMPER CODE OF CONDUCT
The mission of CWES summer camp is to foster in youth an appreciation and understanding of the outdoors and
themselves which will last a lifetime. Our camp programs provide a safe and healthy atmosphere where all youth can
explore and learn about the natural world and other people. CWES staff will work with all campers to comply with the
rules.
All participants are expected to: 1. Participate in all scheduled activities. 2. Follow the directions of CWES staff. 3.
Remain on the grounds, except when accompanied by staff. If driving to camp turn in keys during registration—NO
use of private vehicles during their stay. 4. Campers must leave all personal electronic equipment including cell
phones, hand held gaming devices, tablets, iPods, etc. at home. If they are brought to camp, they will be locked in a
secure location until checkout day. 5. Abide by all other CWES rules including: a) No Smoking. b) No use of
alcoholic beverages, illegal drugs, explosives, or firearms. I have read the above code of conduct with my child and
understand that their failure to abide by these rules may result in expulsion with no refund and agree to pick up my
child if early dismissal from camp is required.
My son or daughter has agreed to comply with the CWES Camper Code of Conduct by signing below.
Guardian Name (Please Print):
Guardian Signature:
Date:
Participant Name (Please Print):
Participant Signature:
Date:
ADDITIONAL INFORMATION
 Yes
 No
Has your child attended camp at CWES before?
Each camper will receive a CWES Summer Camp t-shirt while at camp. Please check the appropriate t-shirt size:
 Youth Small  Youth Medium  Youth Large
 Adult Small  Adult Medium  Adult Large
If attending more than one camp, your camper will receive a $5.00 credit in the Trading Post for each additional camp,
instead of multiple t-shirts.
OFFICE USE ONLY-THANK YOU
Date deposit paid
$
Date paid in full
$
CH#________________ CC/V-MC
QB
Paid by
Paid in full by
CH#________________ CC/V-MC
QB
Pd w/____________________________________________Camp______________________Ch total_______________
MACS_______$________________/__________________
CCS_______$______________/______________