SISTERS OF SUBSTANCE LEADERSHIP RETREAT APPLICATION
2010
Please return to:
Jen Lasachuk
1920 Flintlock Crt.
Mississauga, ONT
L5L 3E1
info@continentalrescueafrica.com / www.continentalrescueafrica.com/sos
*PLEASE PRINT CLEARLY ALL INFORMATION REQUESTED*
*Please note: any registration forms not completely filled out will not be reviewed
Name of Participant:
Address:
City:
Province
Postal Code
Date of Birth (D/M/Y)
Age while attending S.O.S:
Male
Health Card # (Insurance Plan):
Email:
Female
Home Telephone:
Cell Phone # (most reachable):
Grade:_____
Mother’s Name:
Contact #(s):
Father’s Name:
Contact #(s):
Emergency Contact Name:
Relationship:
Emergency Contact #(s):
Has your daughter attended other camps?
Yes
No
Where and When?
School last attended during 2009/2010 Academic Year:
Note: Please include an updated photo of your camper with the registration information.
TRANSPORTATION:
Round-trip bus transportation is available from
World Vision Parking Lot in Mississauga and HWY 401.
Please check if you would like to utilize this service.
Yes
SISTERS OF SUBSTANCE LEADERSHIP RETREAT APPLICATION
2010
PLEASE ANSWER THE FOLLOWING QUESTIONS
We are more interested in getting a sense of who you are and why you think this program is for
you, than we are in you grammar and spelling. So relax and have fun with this application!
1. Why would you like to be a part of the Sisters of Substance Leadership Camp? What
caught your attention about this project:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Tell us about yourself- What strengths, talents and interests will you bring to the Sisters
of Substance Leadership Camp?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. What does leadership mean to you? :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Tell us what is happening in your community. What do you want to
change? ________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
SISTERS OF SUBSTANCE LEADERSHIP RETREAT APPLICATION
2010
5.
What issues are important to you - Here are some ideas, feel free to add more or be
specific :
Racism
Poverty and homelessness
Media images of girls
Health and Self-Esteem
Violence and abuse
Preventing suicide
Drug and alcohol
Women and girls' rights
More opportunities for youth
Community action
Education
Other/ Specifications : ________________________________________________
1. What are you involved in already? (It`s okay you don’t have to be an expert!):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. What impact do you want this leadership camp to have on yourself and on your
community? :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
7. The topics I would most like to discuss/learn about at this event are :
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
SISTERS OF SUBSTANCE LEADERSHIP RETREAT APPLICATION
2010
REGISTRATION FEE: $40 (which includes transportation, accommodations and food, and
snacks for the entire weekend).
How did you hear about Sisters of Substance? Please select all that apply. :
Continental Rescue Africa website
School
Friends
Community organization
Medias
Other: ______________________________________________
T-SHIRT SIZE (please circle one)
Small
Medium
Large
Xtra-Large
SISTERS OF SUBSTANCE LEADERSHIP RETREAT APPLICATION
2010
CAMPER CONTRACT/WISH LIST
I ________________________, a camper at Sisters of Substance have three wishes:
(name of camper)
1. I wish I could learn one new thing this summer and it is
_____________________________________________________________
2. I wish I could do one thing that I have never tried before and it is
___________________________________________________________
3. The one thing about myself I would like people at camp to know about is
___________________________________________________________
I ______________________understand that for Sisters of Substance to be a place where all
campers and staff can feel good, feel safe and have fun. I agree to do the following things to the
best of my ability:
I will treat everyone with courtesy and respect. This means that I will think about other people’s
feelings before I speak and I will not use any part of my body to purposefully hurt anyone.
I will show respect for camp and personal property.
I will be prepared and do my best and try each activity.
I will follow camp rules and accept that there will be consequences if I do not follow these rules.
Signed by the camper___________________________
Date____________________
SISTERS OF SUBSTANCE LEADERSHIP RETREAT APPLICATION
2010
PERSONAL MEDICAL HISTORY
To be completed by every student and returned with the application.
Name:
Birthdate:
Age:
Gender:
Private health insurance company:
Policy No.:
Allergies:
Do you have allergies?
If so, please list them:
Do you carry medic alert identification?
Do you have an epi-pen?
Mobility:
Do you have mobility challenges?
If yes, please describe:
What medications are you currently taking?
List any ongoing medical problems:
List any surgery you have undergone:
Have you ever experienced symptoms related to anxiety, depression, alcohol or
drug addiction, eating disorders or other mental health disorders?
Have you ever sought counseling for any of the above, or other, emotional concerns?
Have you ever, or are you currently taking any medication for any of the above, or other,
emotional concerns?
Do you have any concerns about the physical and emotional challenges of Sisters of
Substance?
Please mention any other medical conditions Sisters of Substance staff should
be aware of. Successful candidates should inform Sisters of Substance staff of
any health-related conditions that may arise prior to the program.
SISTERS OF SUBSTANCE LEADERSHIP RETREAT APPLICATION
2010
ANY MEDICATIONS SENT WITH YOUR DAUGHTER WILL BE HANDED OVER TO
OUR RESIDENCE NURSE WHO WILL DISPENSE AT SAID TIMES.
1. How long has your child been stabilized on these medications?
2. Please circle which medications can be administered to the camper. All medications will be given following the
recommended dosages as written on the consumer packaging, unless otherwise stated.
Tylenol
medication
Advil
Benadryl
Dimetapp Gravol
Polysporin Cortisone
Throat Lozenges
Calamine Aspirin ASA
Pepto Bismol
Cold and Sinus
3. Does the camper have any medical illnesses that they are currently being treated for or has been treated for within the
last 6 months?
4. Has the camper had any injuries within the past 6 months?
5. Are there any restrictions for this camper due to medical concerns?
6. All Immunizations up to date: ___Yes ___ No
This health history is correct and complete to the best of my knowledge, and the person listed has permission
to engage in all prescribed activities except as noted. To the best of my knowledge, this person is in good health
and has not been exposed to any infectious diseases in the past four weeks. If he/she became exposed to any
infectious diseases between now and the time of departure for Sisters of Substance, I understand the Sisters of Substance
Health Staff must be notified before arrival on site of said person.
Physician’s Signature
Date
Phone #
Prescribed and non-prescribed medication will not be administered without the above signature completed.
Attach additional information if necessary