Date Received
Due on or before March 31, 2016
JUNIOR COUNSELOR
APPLICATION FOR CAMERON’S CAMP OF CHAMPS
2016 SUMMER CAMP (May 30- June 2)
Please Complete All Questions. Please Print or Type Information.
SOC. SEC. #:
NAME OF JUNIOR COUNSELOR:
ADDRESS:
CITY/STATE/ZIP:
DATE OF BIRTH:
AGE:
ETHNICITY (Please select one): Caucasian
SEX:
African American
SCHOOL:
Native American
Asian/Pacific Islander
Hispanic
TEACHER:
ADDRESS OF SCHOOL:
CITY/STATE/ZIP:
SCHOOL PHONE:
TEACHER PHONE:
TEACHER E-MAIL:
TYPE OF CLASS: (select one) REGULAR
IS JUNIOR COUNSELOR ON MEDICATION?
LD
YES
DOSAGE:
EMR
TMR
NO
OTHER:
TYPE:
TIME:
AMOUNT:
DOES JUNIOR COUNSELOR HAVE ANY PHYSICAL PROBLEMS? YES
DOES THE JUNIOR COUNSELOR HAVE (select one)
NO
TYPE:
ASTHMA
ALLERGIES
NAME OF JUNIOR COUNSELOR’S PHYSICIAN
DIABETES
PHONE:
JUNIOR COUNSELOR’S T-SHIRT SIZE: (Select One)
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:
PHONE:
ADDRESS:
CITY/STATE/ZIP:
Teacher or Parent: Please write a short statement about this counselor informing us of specific needs, etc.
Transportation to and from camp will be the responsibility of the parents.
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 "Junior Counselor),
hereby request permission for the Junior Counselor to participate in the Camping Program.
I represent and warrant to you that the Junior Counselor is physically and mentally able to participate in the Camping Program.
On behalf of the Junior Counselor and myself, I acknowledge that the Junior Counselor 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 Junior Counselor.
In permitting the Junior Counselor to participate, I am specifically granting permission to you to use the likeness, voice and words
of the Junior Counselor 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 Junior Counselor 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 Junior Counselor.
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.
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
City, State, Zip
Date
APPLICATION MUST BE POSTMARKED NO LATER THAN MARCH 31, 2016