Does camper have: Asthma ____ Hay Fever ___ Use Inhaler ___
Use Epipen ___
Should camper carry Inhaler or Epipen for emergency use?
Yes _____ No ____
Loon Bay United Church Youth Camps 2014
Our mission is to provide through the ministry of camping, with God’s
help, an experience of Christian community learning for all people, shown
in an outdoor setting as part of the fabric of education, outreach, and
evangelism of The United Church of Canada.
Is there any reason why camper cannot participate in all camp activities? If so, list
any restrictions: _______________________________________________________
Any medications to be given at camp? Yes ___ No ____
List prescription medication as well as any other medications the parent requires to
be given at camp if needed (such as Benadryl, Gravol, Tylenol). Parents must discuss
these medications with the Camp Director and the Camp Health Care Provider on
child’s arrival at camp.
Name of medication: ______________________________________________
Times to be taken: ________________________________________________
Any special Instructions: ___________________________________________
Name of medication: ______________________________________________
Times to be taken: ________________________________________________
Any special Instructions: ___________________________________________
All medications brought to camp must be given to the Director / Health Care
provider. Exceptions: 1. Epipens 2. Inhalers needed for camper emergency use.
1.
Send medication in a pharmacy container with name of camper,
medication and dosage information clearly visible.
2.
Epipens and inhalers for emergency use should be carried in a fanny pack.
(Two Epipens may be necessary with severe allergies due to distance from camp to
hospital)
To the best of my knowledge, my child is in good health. I will notify the camp if my
child is exposed to an infectious disease during the three weeks prior to arriving at
camp. The Health Care provider has my permission to administer the medications
listed on the Health Care Form. In case of an emergency, I understand that every
effort will be made to contact me (or contact person). In the event that I cannot be
reached, I hereby give my permission to the physician selected by the Camp Director
and the Health Care Provider to hospitalize, secure proper treatment, to order
injection, anaesthetic, or approve surgery for my child.
Parent’s Signature: ________________________________________________
Camp Number: ______ Camp Date: __________________ Please indicate if you
wish to receive a call from the Health Care Provider prior to arrival at camp to
discuss any health and/or other confidential concerns: Yes _____ No ______
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Please note that all information on this form will remain confidential.
Camp Board endeavours to make the camp experience available to as many children
as possible. Campers who wish to attend more than one camp should indicate first
and second choices. Acceptance to a second camp will be based on availability of
space. For applications to one camp only, please place an X next to the camp you
wish to attend. (Appropriate camp should be based on camper’s age by Dec 31-14)
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Camp I
Camp II
Camp III
Camp IV
Camp V
Camp VI
Junior (7-9)
Intermediate (10-12)
Teen (13-16)
Junior (7-9)
Intermediate (10–12)
Teen (13-16)
July 6 – 10
July 13 – 17
July 20 – 24
July 27 – 31
August 3 – 7
August 10 –14
Name_________________________________ Gender: M ___ F___ Age ___
Mailing Address: ____________________________________________________
Postal Code: _____________________ Email: ____________________________
Parent/Guardian: ___________________________________________________
Home # ________________ Cell # _________________ Work # ______________
Have you attended Loon Bay Camp before: Yes _______ No ________
Home Church: _____________________________________________
Campers are placed in small groups for some activities and chores. Campers may
choose one person that (s)he would like to be in a group with (make sure campers
name each other). We may not be able to accommodate all requests.
Name: __________________________________________________________
Registration fee for camps (I-VI) is $125 per camper. A deposit of $50 is required
with the application. The remainder is due upon arrival at the camp. Receipts for
Income Tax purposes will be provided. Cheque or money order to be made to the
Loon Bay United Church Camp and mailed with this application and completed
Health Form to:
Loon bay United Church Camp c/o Gary Ross, P O Box 1439
Lewisporte, A0G 3A0.
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Applications will be based on postmarked date
EMAILED OR PHONE IN APPLICATIONS ARE NOT ACCEPTED. However, hand
delivered applications delivered to the Loon Bay United Church Youth Camp on or
after June17th until August 7th WILL BE ACCEPTED. Any inquires pertaining to
mailed applications should be directed to the volunteer registrar’s voicemail at 5352990. The registrar will get back you. Please respect the privacy of our volunteer
registrar and refrain from calling him/her at home. Any inquires pertaining to hand
delivered applications contact Catherine Lewis at 261-2260 on or after June 17th.
No child will be accepted for camp without all portions of the application and
Health Form being completed. Registration time will be between 2-3 pm Sunday on
the first day of each camp week and pick up time will be 2-3 pm Thursday on the
last day of each camp week. Please note that financial assistance is available to
parents when it is needed for a child to attend camp.
Please view the Loon Bay United Church Camp Face Book Page and the Loon Bay
United Church Camp Web Page for information on upcoming Youth camps, previous
and current camp activities, and to download an application form.
Please note that health care at camp will be provided by a trained first aider unless a
volunteer nurse is available.
Priority will be given to United Church families until June 15th. Thereafter,
applications will be accepted as they arrive.
_________________________________
Signature of parent/guardian
_____________________
Date
Photos taken at camp may be used for promotional purposes. Please sign below if
you give permission for your child’s photo to be used this way.
_________________________________
Signature of parent/guardian
_____________________
Date
Camper Health Record for the Loon Bay United Church Camping Centre
Each camper is responsible for the following personal items:
•
sleeping bag / pillow / flashlight
•
notebook / pen
•
swim wear / sunscreen / sunglasses / fly dope( camp chair is optional )
•
rain wear / rain boots / cap or hat
•
changes of clothing
•
towels / face clothes / toiletries
Camper Name: ___________________________________ Male ___ Female ___
Camp activities may vary from age to age:
•
Arts and Crafts ( Including Tie Dye )
•
Sports and Games
•
Nature Study / Hiking
•
Swimming / Canoeing
•
Bible Study
•
2014 Time Capsule Burial
Names of parents/guardians: __________________________________________
Traditionally each camp has both a Talent Show and a Social Nite. Please feel free to
bring items needed for these events.
Canteen services will be available to campers. Your child will require canteen
money. Snacks are provided for all campers in the afternoons.
*** Please do not bring snack foods or cell phones to camp.
Please contact us at the above numbers if you are interested in a Summer Camp
Volunteer position.
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Date of Birth: ________________________ MCP # ________________________
Address: ___________________________________________________________
Home # _______________ Cell # _________________ Work # ________________
Family Doctor: __________________________ Phone #: ___________________
We make every effort to accommodate campers with medical problems or
disabilities. It is important for us to be aware of these to ensure the comfort and
safety of your child. Use separate sheet if necessary. Check any conditions that may
be useful for our camp staff to know:
Bed wetting _____ Poor appetite _____ Fear of dark _____ Sleep walking _____
Other (please describe) _______________________________________________
Are camper’s immunizations up to date __________ Allergies? Yes ____ No ____
Allergic to drugs (specify) ______________________________________________
Food Allergy _________________________________________________________
Allergy to bee stings _________________ Allergy to wasp stings ______________
Type of allergic reactions (rash, hay fever, breathing difficulties, etc.):
___________________________________________________________________
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