Date Received
Due on or before March 31, 2016
CAMPER
APPLICATION FOR CAMERON’S CAMP OF CHAMPS
2016 SUMMER CAMP (May 30 – June 2)
Please Complete All Questions. Please Print or Type Information.
NAME OF CAMPER:
SOC. SEC. #:
ADDRESS:
CITY/STATE/ZIP:
DATE OF BIRTH:
AGE:
ETHNICITY: (Select) Caucasian
SEX: (Please select) FEMALE
African American
Native American
SCHOOL:
MALE
Asian/Pacific Islander
TEACHER:
ADDRESS OF SCHOOL:
CITY/STATE/ZIP:
SCHOOL PHONE:
TEACHER PHONE :
TEACHER E-MAIL:
TYPE OF CLASS: (Select one) REGULAR
IS CAMPER ON MEDICATION? YES
DOSAGE:
EMR
LD
NO
OTHER
TYPE:
TIME :
AMOUNT:
NO
DOES CAMPER HAVE ANY PHYSICAL PROBLEMS? YES
DOES THE CAMPER HAVE (Select)
TMR
ALLERGIES
TYPE:
ASTHMA
NAME OF CAMPER'S PHYSICIAN:
DIABETES
PHONE:
CAMPER'S T-SHIRT SIZE: (Circle One - T-shirts tend to run small.)
CHILD: S
M
L
ADULT: S
M
L
XL
PARENT/GUARDIAN NAME:
ADDRESS:
CITY/STATE/ZIP:
PHONE NUMBER(S): HOME:
WORK:
PERSON OTHER THAN PARENT/GUARDIAN TO BE NOTIFIED IN CASE OF EMERGENCY:
NAME:
ADDRESS:
PHONE:
CITY/STATE/ZIP:
Teacher or Parent: Please write a short statement about this camper informing us of specific needs, etc.
Transportation to and from camp will be the responsibility of the camper’s parents.
Hispanic
Date Received
Due on or before March 31, 2016
PLEASE READ THE FOLLOWING CAREFULLY AND SIGN:
I, the undersigned parent and/or legal guardian of the above named applicant (hereinafter referred to as the "Camper"), hereby request permission
for the camper to participate in the Camping Program.
I represent and warrant to you that the Camper is physically and mentally able to participate in the Camping Program.
On behalf of the Camper and myself, I acknowledge that the Camper will be using facilities at his/her own risk and on my behalf, hereby release,
discharge and indemnify Cameron University, the School of Education and Behavioral Sciences, and camp staff from all liability for injury to
person or damage to property of myself and Camper.
In permitting the Camper to participate, I am specifically granting permission to you to use the likeness, voice and words of the Camper in television,
radio, films, newspapers, magazines, and other media, and in any form not heretofore described, for the purpose of advertising or communicating
the purpose and/or activities of the Camping Program and in appealing for funds to support such activities.
Since I will not personally be present at Camp activities in which the Camper is to participate, so as to be consulted in case of necessity, you are
authorized on my behalf and at my account to take such measures and arrange for such medical and hospital treatment as you may deem advisable
for the overall health and well-being of the Camper.
The organizers, officers, directors, agents, employees, or university students of the Camping Program, and Cameron’s administration, faculty, and
staff, are hereby released, acquitted, and discharged from any claim(s) for damage(s) or suit(s) by reason of the injury, illness, or damage to
person(s) or property during the course of the Camping Program, including transportation to or from the Camp and/or to any event(s), and in that
regard, I hereby covenant not to sue or bring legal action against the aforementioned parties, including the Camping Program and Cameron
University, for any such injury(s) or damage(s).
I, the undersigned, as a parent (or guardian) of the above named minor, have read and fully understand the provisions of the above release and have
explained them to said minor. I hereby agree that I and said minor will be bound thereby and I shall defend you and hold you harmless from any
disaffirmation thereof by said minor.
NOTE: A limited number of scholarships are available. If you judge yourself to be in financial need of a scholarship, please comply with the
following procedures and check the appropriate blank.
I request that my child(ren) be considered for a scholarship. YES
NO
Is your child being sponsored by a special education teacher or other group? YES
Is the parent/guardian paying for the Camper's fee? YES
NO
(If yes, disregard the next paragraph.)
NO
If you are requesting a scholarship, at least one letter of support will be needed. You may request this support from your minister, teacher, school
principal, etc. Letters must be postmarked no later than March 31, 2016. These letters should be mailed to the address below. In addition,
even if you are requesting financial support through a scholarship, a check for the camp fee ($100.00) must be included with your camp
application if you wish a guaranteed reservation for your child. (Guaranteed reservations are subject to available space and eligibility.) If
your child is awarded a scholarship, your check will be returned with the award document. Applications received with the $100.00
camp fee will be given equal consideration. However, if the scholarship fund is expended at that point, applications without the $100.00
camp fee will not be processed. Should your child be sponsored by a school, church or other organization, that agency should contact the
camp director for verification whereby the camp fee will not be required by that respective parent.
Signature of Parent/ Legal Guardian
Address
PLEASE MAIL APPLICATION AND SIGNED RELEASE TO:
Cameron University
Cameron’s Camp of Champs
Dr. Ronna Vanderslice
2800 West Gore Blvd.
Lawton, OK 73505
CAMP FEE: $100.00
City, State, Zip
MAKE CHECK PAYABLE TO:
Cameron’s Camp of Champs
Date
APPLICATION MUST BE POSTMARKED NO LATER THAN MARCH 31, 2016