ASYMCA Camp Rockfish Application Documents


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ASYMCA Camp Rockfish Application Documents

  1. 1. Camp Rockfish Application Summer 2012 Mail to: 226 Camp Rockfish Rd, Parkton, NC 28371 Attn: Resident Camp Registration Phone # (910) 425-3529 Fax # (910) 875- 6177 Website: www.camprockfish.orgCampers Name________________________________ Preferred Name_________________ Male__ Female__Birthday (M/D/Y)_________________ Grade entering ___________ Age during camp_______________Child’s Mailing Address________________________________City____________________State____ Zip _______Child’s Physical Address_______________________________City____________________State____ Zip ______(if different from above)E-Mail for updated Rockfish information ________________________________________________________Please Indicate with whom camper lives: __Both Parents __Mother __Father __GuardianParents are: __Married __Separated __Divorced __Single __Re-married __Widowed Mother/Guardian #1_________________________________ Home Phone (___)__________________________ Cell Phone #(___)_________________________ Work Phone#_____________________ Home Adress_____________________________________City________________State_____ Zip_____________ Father/Guardian #2_________________________________ Home Phone (___)__________________________ Cell Phone # (___)_________________________ Work Phone # (___)_____________________ Home Adress__________________________________City__________________State_____Zip_______________Emergency Contact (in case we cannot get in touch with parents/guardians)1. ________________________ Relationship to camper __________________ Daytime Phone #(___)______________Address __________________________City _______________State _____Zip_______Work # (___)______________2._________________________ Relationship to camper __________________ Daytime Phone #(___)______________Address __________________________City _______________State _____Zip_______Work # (___)______________Insurance Carrier:_____________________________________ Subscriber: _________________________________ Subscriber Number: _________________________________Sheltermate Request _______________________________________________Have you been to Camp Rockfish before __Yes __No If yes, what years?________________How did you hear about Camp Rockfish? __Internet __Camp Fair __Friend __Former Camper/Staff__ Print __Ad __Sibling __Attended __Other______________________ ___ I have included the $100/$50 deposit towards my camper’s overall balance. ___ I have included the $100/$50 deposit plus an additional $______ towards my camper’s overall balance. ___ I have included $______ towards my camper’s store account. TOTAL ($):_______With registration by mail, we encourage a check payment. However, if needed a credit cardpayment can be made once forms are received. A Rockfish staff member will contact you forcredit card information to complete the registration process.If you have any questions, our office can be contacted by phone at (910)425-3529 or by email camp fees are due by June 1, 2012.
  2. 2. Camp Session Sign upThe chart on the following page shows all programs that we have available for the summer.Within the chart, please check the white box corresponding with the camp of your choice.When turning in this application, please include the initial deposit of $100 for ResidentCamp and $50 for Day Camp. This deposit will go towards your overall camp balance.There is also the option of providing your camper with money for the camp store. When yourapplication and fee have been processed, you will receive a confirmation letter or emailincluding our parent pack. If you have any further questions, please call (910) 425-3529 ext.23.All paperwork is due on the registration day for your camp. Chart Key: July 29 – Aug. 4 June 10-16 June 17-23 June 24-30 Aug. 12-18 July 15-21 - White boxes indicate which July 22-28 Aug. 5-11 July 8-14 July 1-7 Resident Camp weeks of programs are available. - Gray Boxes indicate which weeks programs are closed. Traditional Survivor Program Prices: Night Owls Traditional - $445 Roller Coaster Survivor - $465Extreme Explorers Night Owls - $450 Outbounders Roller Coaster - $750 Water Extreme Explorers - $625 Kayak Venture Outbounders - $720 Water - $455 W.Y.L.D. Bunch Kayak Venture - $490 Footprints W.Y.L.D. Bunch - $990 Family Camp Mini - $205 Day - $150 June 17-20 June 20-23 July 15-18 July 18-21 Mini Camp July 30 – Aug. 3 June 11-15 June 18-22 June 25-29 Aug. 13-17 July 16-20 July 23-27 Aug. 6-10 July 9-13 July 2-6Day CampI verify that all of the above information is true and correct to the best of my knowledge.Signature_____________________________________________________________________ Date______________For office use only: / / __ Balance$_________ Date Deposit Received: ________
  3. 3. CAMPER HEALTH Dates will attend camp: from ______________to_____________ Camper Name ______________________________________________________________________ (For Camp Use) Cabin or Group____________________ (For Camp Use) Session Code(s): ________________ Month/Day/Year Month/Day/Year HISTORY FORM 1 Camper Name: _____________________________________________________________ First Middle LastDeveloped and reviewed by: American Camp Association, Male Female Birth Date ____________ Age on arrival at camp: ________American Academy of Pediatrics Council on School Health, & Month/Day/YearAssociation of Camp Nurses To Parent(s)/Guardian(s): Please follow the instructions below. Attach additional information if needed. FirstMail this form to the address below by _______ (date) 1) Complete pages 1, 2 and 3 of this form (FORM 1) and make a copy. 2) Send the original, signed FORM 1 to camp by the requested date. 3) Complete the top of FORM 2 (CAMPER HEALTH-CARE RECOMMENDATIONS) and provide the copy of FORM 1 with FORM 2 to your child’s health-care provider for review and completion. 4) After it has been completed and signed by your child’s health-care provider, return FORM 2 to camp by the requested date.Camper Home Address: ______________________________________________________________________________________________________ Street Address City State Zip CodeParent/guardian with legal custody to be contacted in case of illness or injury: RelationshipName: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Email: _______________________ MiddleHome Address: _____________________________________________________________________________________________________________(If different from above) Street Address City State Zip CodeSecond parent/guardian or other emergency contact: RelationshipName: ____________________________ to Camper: ________________Preferred Phones: (______) ________________(______)_________________ Email: _______________________Additional contact in event parent(s)/guardian(s) can not be reached: RelationshipName(s): __________________________ to Camper: ________________ Preferred Phones: (______) ________________(______)_________________Allergies: No known allergies. This camper is allergic to: Food Medicine The environment (insect stings, hay fever, etc.) Other (Please describe below what the camper is allergic to and the reaction seen.) LastDiet, Nutrition: This camper eats a regular diet. This camper eats a regular vegetarian diet. This camper has special food needs. (Please describe below.)Restrictions: I have reviewed the program and activities of the camp and feel the camper can participate without restrictions. I have reviewed the program and activities of the camp and feel the camper can participate with the following restrictions or adaptations. (Please describe below.)Medical Insurance Information:This camper is covered by family medical/hospital insurance Yes NoInclude a copy of your insurance card if appropriate; copy both sides of the card so information is readable.Insurance Company______________________________ Policy Number___________________________Subscriber_____________________________________ Insurance Company Phone Number (______) ___________________Parent/Guardian Authorization for Health Care:This health history is correct and accurately reflects the health status of the camper to whom it pertains. The person described has permission to participate inall camp activities except as noted by me and/or an examining physician. I give permission to the physician selected by the camp to order x-rays, routine tests,and treatment related to the health of my child for both routine health care and in emergency situations. If I cannot be reached in an emergency, I give mypermission to the physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for this child. I understand the information onthis form will be shared on a "need to know" basis with camp staff. I give permission to photocopy this form. In addition, the camp has permission to obtain acopy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.Signature of Custodial RelationshipParent/Guardian __________________________________________________________________Date: to Camper: _______________________If for religious or other reasons you cannot sign this, contact the camp for a legal waiver which must be signed for attendance. Page 1/4
  4. 4. CAMPER HEALTH HISTORY FORM 1 Camper Name: ________________________________________________ First Middle LastDeveloped and reviewed by: American Camp Association, American Academy of Pediatrics Council on Birth Date: ____________School Health, & Association of Camp Nurses Month/Day/YearImmunization History: Provide the month and year for each immunization. Starred ( ) immunizations must be current. Copies of immunization formsfrom health-care providers or state or local government are acceptable; please attach to this form. Immunization Dose 1 Dose 2 Dose 3 Dose 4 Dose 5 Most Recent Dose Month/Year Month/Year Month/Year Month/Year Month/Year Month/YearDiptheria, tetanus, pertussis(DTaP) or (TdaP)Tetanus booster(dT) or (TdaP)Mumps, measles, rubella(MMR)Polio(IPV)Haemophilus influenzae type B(HIB)Pneumococcal(PCV)Hepatitis BHepatitis AVaricella Had chicken pox(chicken pox) Date:Meningococcal meningitis(MCV4)Tuberculosis (TB) test Date: Negative PositiveIf your camper has not been fully immunized, please sign the following statement: I understand and accept the risks to my child from notbeing fully immunized.Signature of Custodial RelationshipParent/Guardian: ______________________________________________________________Date: to Camper: __________________________Medication: This camper will not take any daily medications while attending camp. This camper will take the following daily medication(s) while at camp:"Medication" is any substance a person takes to maintain and/or improve their health. This includes vitamins & natural remedies. Please review campinstructions about required packaging/containers. Many states require original pharmacy containers with labels which show the camper’sname and how the medication should be given. Provide enough of each medication to last the entire time the camper will be at camp.Name of medication Date started Reason for taking it When it is given Amount or dose given How it is given Breakfast Lunch Dinner Bedtime Other time:_____________ Breakfast Lunch Dinner Bedtime Other time:_____________ Breakfast Lunch Dinner Bedtime Other time:_____________The following non-prescription medications may be stocked in the camp Health Center and are used on an as needed basis to manage illness and injury.Cross out those the camper should not be given.Acetaminophen (Tylenol) Ibuprofen (Advil, Motrin)Phenylephrine decongestant (Sudafed PE) Pseudoephedrine decongestant (Sudafed)Antihistamine/allergy medicine Guaifenesin cough syrup (Robitussin)Diphenhydramine antihistamine/allergy medicine (Benadryl) Dextromethorphan cough syrup (Robitussin DM)Sore throat spray Generic cough dropsLice shampoo or cream (Nix or Elimite) Antibiotic creamCalamine lotion AloeLaxatives for constipation (Ex-Lax) Bismuth subsalicylate for diarrhea (Kaopectate, Pepto-Bismol)Copyright 2008 by American Camping Association, Inc. Page 2/4 Rev. 1/2007 LEE/EAW
  5. 5. CAMPER HEALTH HISTORY FORM 1 Camper Name: ________________________________________________ First Middle LastDeveloped and reviewed by: American Camp Association, American Academy of Pediatrics Council on Birth Date: ____________School Health, & Association of Camp Nurses Month/Day/YearGeneral Health History: Check "Yes" or "No" for each statement. Explain “Yes” answers below.Has/does the camper:1. Ever been hospitalized? …………………………. Yes No 11. Had fainting or dizziness? ..................................................... Yes No2. Ever had surgery? .............................. …………. Yes No 12. Passed out/had chest pain during exercise? ….……………. Yes No3. Have recurrent/chronic illnesses? .......……….… Yes No 13. Had mononucleosis ("mono") during the past 12 months?... Yes No4. Had a recent infectious disease? ....... …………. Yes No 14. If female, have problems with periods/menstruation?.…….. Yes No5. Had a recent injury? ........................... …………. Yes No 15. Have problems with falling asleep/sleepwalking? ............... Yes No6. Had asthma/wheezing/shortness of breath?...... Yes No 16. Ever had back/joint problems?…….………...……………...... Yes No7. Have diabetes? .................................. …………. Yes No 17. Have a history of bedwetting?………………….……………... Yes No8. Had seizures? .................................................... Yes No 18. Have problems with diarrhea/constipation?……………….... Yes No9. Had headaches? …………………………………. Yes No 19. Have any skin problems?…………………….......................... Yes No10. Wear glasses, contacts, or protective eyewear? Yes No 20. Traveled outside the country in the past 9 months?.............. Yes NoPlease explain “Yes” answers in the space below, noting the number of the questions. For travel outside the country, please name countries visitedand dates of travel.Mental, Emotional, and Social Health: Check "Yes" or "No" for each statement.Has the camper:1. Ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (AD/HD)? ………………………........ Yes No2. Ever been treated for emotional or behavioral difficulties or an eating disorder?……............................................................................. Yes No3. During the past 12 months, seen a professional to address mental/emotional health concerns?……….…………………………………. Yes No4. Had a significant life event that continues to affect the camper’s life?...................................................................................................... Yes No (History of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)Please explain “Yes” answers in the space below, noting the number of the questions. The camp may contact you for additional information.Health-Care Providers:Name of camper’s primary doctor(s): ____________________________________________________ Phone: (________) _______________________Name of dentist(s):___________________________________________________________________ Phone: (________) _______________________Name of orthodontist(s):_______________________________________________________________ Phone: (________) _______________________What Have We Forgotten to Ask? Please provide in the space below any additional information about the camper’s health that you think important orthat may affect the camper’s ability to fully participate in the camp program. Attach additional information if needed. Parents/Guardians: STOP here. The rest of this is form is completed when the camper arrives at camp. Keep a copy for your records.Copyright 2008 by American Camping Association, Inc. Page 3/4 Rev. 1/2007 LEE/EAW
  6. 6. CAMPER HEALTH HISTORY FORM 1 Camper Name: ________________________________________________ First Middle LastDeveloped and reviewed by: American Camp Association, American Academy of Pediatrics Council on Birth Date: ____________School Health, & Association of Camp Nurses Month/Day/Year Individual Health Record (For Camp Use Only) Initial Screening Date/Time: _________ Initials: ____________ Screening has been conducted according to camp protocol and significant findings noted as follows: A. Any signs/symptoms of illness or injury upon arrival?........................ No Yes as noted below B. History of exposure to communicable disease?.................................. No Yes as noted below C. Additions or corrections to information on this health history?............ No Yes as noted below D. Medication given to health-care staff?.................................................. No Yes as noted below E. Any signs/symptoms of head lice?...................................................... No Yes as noted below Provider notes: (date/time/initial all entries) _____________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ Exit Note: Check one of the following: Left camp this day with no reported illness or injury symptoms. Left camp this day with the following problem/concern: _____________________________________ ________________________________________________________________________________________________________________ This person was told about the problem and instructed about follow-up as noted above: __________________________________________ Date/Time: ___________ Initials: __________Copyright 2008 by American Camping Association, Inc. Page 4/4 Rev. 1/2007 LEE/EAW
  7. 7. Camper Name ______________________________________________________________________ (For Camp Use) Cabin or Group____________________ (For Camp Use) Session Code(s): ________________CAMPER HEALTH-CARE RECOMMENDATIONS To Parent(s)/Guardian(s): Complete this section and give this form (FORM 2) and a copy of yourby LICENSED MEDICAL PERSONNEL FORM 2 completed CAMPER HEALTH HISTORY FORM (FORM 1) to your child’s health-care provider for review.Developed and reviewed by: American Camp Association, Dates will attend camp: from ______________to_____________American Academy of Pediatrics Council on School Health, & Month/Day/Year Month/Day/YearAssociation of Camp Nurses Camper Name: _____________________________________________________________ First Middle Last Male Female Birth Date ____________ Age on arrival at camp ________ FirstMail this form to the address below by _______ (date) Month/Day/Year Camper home address: ________________________________________________________ ____________________________________________________________________________ City State Zip Code Custodial parent(s)/guardian(s) phone: (_______)______________ (_______)____________ Parent(s)/guardian(s) stop here. Rest of form to be completed by medical personnel.The following non-prescription medications are Medical Personnel: Please review the CAMPER HEALTH HISTORY FORM (FORM 1) and complete allcommonly stocked in camp Health Centers and are remaining sections of this form (FORM 2). Attach additional information if needed.used on an as needed basis to manage illness andinjury. Medical personnel: Cross out those items the Physical exam done today: Yes No (If “No,” date of last physical: ___________)camper should not be given. Month/Day/Year ACA accreditation standards specify physical exam within last 24 months. MiddleAcetaminophen (Tylenol)Ibuprofen (Advil, Motrin)Phenylephrine (Sudafed PE) Weight: _______ lbs Height: _____ft_____in Blood Pressure_______/_______Pseudoephedrine (Sudafed)Chlorpheneramine maleate Allergies: No Known AllergiesGuaifenesinDextromethorphan To foods (list):Diphenhydramine (Benadryl)Generic cough drops To medications: (list):Chloraseptic (Sore throat spray)Lice shampoo or scabies cream (Nix or Elimite) To the environment (insect stings, hay fever, etc.– list):Calamine lotionBismuth subsalicylate (Pepto-Bismol) Other allergies: (list):Laxatives for constipation (Ex-Lax)Hydrocortisone 1% cream Describe previous reactions:Topical antibiotic creamCalamine lotion LastAloeDiet, Nutrition: Eats a regular diet. Has a medically prescribed meal plan or dietary restrictions:(describe below)The camper is undergoing treatment at this time for the following conditions: (describe below) None.Medication: No daily medications. Will take the following prescribed medication(s) while at camp: (name, dose, frequency—describe below)Other treatments/therapies to be continued at camp: (describe below) None needed.Do you feel that the camper will require limitations or restrictions to activity while at camp? No Yes If you answered “Yes” to the question above, what do you recommend? (describe below—attach additional information if needed)“I have reviewed the CAMPER HEALTH HISTORY FORM (FORM 1), and have discussed the camp program with the camper’sparent(s)/guardian(s). It is my opinion that the camper is physically and emotionally fit to participate in an active camp program (except asnoted above.)Name of licensed provider (please print): __________________________________Signature: _________________________________Title: _________Office Address_____________________________________________________________________________________________________________ Street City State Zip Code Telephone: (________)_____________________ Date:_______________________Copyright 2008 by American Camping Association, Inc. Rev. 2/07 LEE/EAW
  8. 8. ADVENTURE WAIVER Rockfish Camp & Retreat Center PARTICIPATION ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS and RELEASE AND INDEMNITY AGREEMENTIn consideration of the services of Camp Rockfish, and its chartering organization, NC United Methodist Camp & Retreat Ministries,INC., and each of their respective agents, employees, officers, directors, trustees, affiliates, representatives, independent contractors,volunteers (including consulting physicians), and any and all other persons or entities acting under their direction and controlassociated  with  them  (collectively  referred  to  as  “ROCKFISH”), participant (and parent or guardian of a participant) acknowledgesand agrees as follows: ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS I  understand  that  participant  and  parents  share  the  responsibility  for  participants’  safety,  for  managing  the  risks  and  for  determiningthe  participant’s  suitability  for  the  program  in  which  he/she  will  participate.  I  have  accurately  completed  any  required ROCKFISHapplication and medical forms and have reviewed all ROCKFISH program information provided to me. I agree to have my child obey allROCKFISH rules, regulation and policies. My child has no mental or physical problems or limitations that might  affect  my  child’s  ability  to  participate that have not been disclosed to ROCKFISH in writing, I have had the opportunity to ask question about the program activities andthe risks of the program in which my child will participate. I understand and acknowledge that the program(s) in which my child will participate has risks and it is impossible to anticipateevery activity in which my child will engage. The activities will depend on the program but may be physically strenuous. These activitiesmay be instructional, educational, or adventurous and may include but are not limited to: hiking, archery, BB guns, skate park, camping,including cooking over stoves, open fires or by other means; ropes and/or challenge courses (traversing ropes suspended off the ground,potentially at great heights, zip lines and other such activities); physical problem-solving activities; rock, wall or tower climbing; repelling;water activities including rafting, canoeing, kayaking, or swimming; vehicle travel, and rescue scenarios (real or simulated). I understand thatmy child may engage in other activities not listed above. Activities may take place in North Carolina or the United States. Participants mayalso be in urban or other areas with exposure to individuals who are not under ROCKFISH’s  supervisions  or  control.  The  planned  program  may be modified for any number of reasons, including convenience, weather, emergencies or unexpected conditions. It is impossible to know or list every risk associated with every activity. Some, but not all, of the risks my child may encounterinclude: unpredictable or harsh weather; lightning exposure to extreme temperatures (high heat or cold); drowning; wild animals and marinelife; improper or malfunctioning equipment; slipping, falling or being struck by objects or persons; risks caused or complicated by anymental, physical or emotional conditions any participant may have; physical contact with other participants or other individuals; and othernatural or man-made hazards. Another risk is the potential misjudgment by ROCKFISH instructors, volunteers, other staff members, co-participants or contractors related to my  child’s  participation,  including  but  not  limited  to  decisions  regarding  my  child’s  physical  condition  and capabilities, weather, water, terrain, route or medical treatment. All of these risks are inherent to the activities in ROCKFISH’s program,which means that they cannot be changed or eliminated without altering the essential elements of the activity. I acknowledge that participating in an ROCKFISH program involves inherent risks and other risks, hazards and dangers includingsome not listed above that can cause or lead to death, injury, illness, property damage, mental or emotional trauma, or disability. Furthermore,activities may take place several hours or days from any medical facility or where communication, transportation, or evacuation is subject todelay.  I  understand  that  ROCKFISH  cannot  assure  my  child’s  safety  and  does  not  seek  to  eliminate  all  of  these  risks  of  the  activities of mychild’s  ROCKFISH  program,  whether  inherent  to  not  whether  described  or  not.Parent/Guardian Initials: _______________ Participant Initials: _______________
  9. 9. RELEASE AND INDEMNITY AGREEMENTI release ROCKFISH from, and agree not to pursue claim or sue ROCKFISH for, any liability, claim, suit or expense in any way associated with mychild’s enrollment or participation or the use of any equipment or facilities in the ROCKFISH program. Neither I nor  anyone  acting  on  my  child’s  behalf will make a claim against ROCKFISH as a result of any loss, injury, illness, damage or death suffered by my child. This release includes anylosses caused or alleged to be caused, in whole or in part, by the negligence of ROCKFISH to the fullest extent by law and includes claims for breachof contract or any other type of suit. I do not waive any claims for gross negligence or willful or wanton conduct. I further agree to defend and indemnity ROCKFISH (to pay or reimburse  ROCKFISH  for  money  it  is  required  to  pay,  including  attorney’s  fees and costs) with respect to any and all claims brought by or on behalf of me, my child, a family member, a co-participant, or any other person forany  claims  related  to  my  child’s  participation  in  the  program  or  my  child’s  use  of  equipment  or  facilities,  including  claims  that  ROCKFISH  instructors, staff, or volunteers were negligent. However, I do not agree to indemnity ROCKFISH for claims of gross negligence or willful wantonconduct. ADDITIONAL PROVISIONS I agree that the substantive law of North Carolina governs this document and any dispute or suit I have (or my child has) with ROCKFISHregardless  of  the  “conflict  of  law”  rules.)  Any  mediation,  suit,  or  other  proceeding  must  be  filed or entered into only in North Carolina. I agree to payall  attorney’s  fees  and  costs  incurred  by  ROCKFISH  in  defending  a  claim  or  suit  if  the  claim  is  withdraws  or  to  the  extent  a  court determines thatROCKFISH is not liable for the injury or loss. The assumption of risks, release, indemnity agreement, and all other provisions in this document are intended to be interpreted and enforcesto the fullest extent allowed by the law. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken withoutany effect of the enforceability of the remaining provisions, which shall continue in full force and effect. ROCKFISH has permission to use mychild’s  photo  or  image  for  sale  or  reproduction  in  any manner it desires, including advertising or display. ROCKFISH reserves the right to removeany participant from the program when staff or an instructor believes, in his/her sole discretion, the participant presents safety concern or medicalrisk, is disruptive or acts in any manner detrimental to the program. If my child is dismissed or departs for any reason, I will be responsible for allcosts of early departure whether for medical reason, dismissal, personal emergencies, or otherwise. I HAVE CAREFULLY READ, UNDERSTAND, AND VOLUNTARILY SIGN THIS DOCUMENT, I UNDERSTAND THATI AM SURRENDING CERTAIN LEGAL RIGHS. I AGREE THAT THIS FORM SHALL BE BINDING ON ME, MY MINORCHILDREN AND OTHER FAMILY MEMBERS, AND MY HEIRS, EXECUTORS, REPRESENTATIVES AND ESTATE.If participant is under the age of 18 at the time this document is signed, a parent or legal guardian must sign the release inaddition  to  the  participant’s signing. Participant’s  Printed  Name:  ____________________________________________________________________________________________________________ Participant’s  Signature:  _______________________________________________________________________________________________________________ Date: _____________________ Phone: __________________________________________ Date of Birth: ____________________________________________ Address: _____________________________________________________ City: ________________________ Sate: ___________ Zip: _____________________ TO READ AND SIGN BY PARENT/GUARDIAN OF MINOR I hereby represent that I am the parent or guardian of the minor whose name appears above, I have read and consent/agree to the terms and conditions herein, on behalf of said minor and myself. X_____________________________________ _______________________________________ ________________ Guardian Signature Print Name Date
  10. 10. Rockfish Camp & Retreat Center 226 Camp Rockfish Road Parkton, NC 28371 910-425-3529 Camper Behavior Contract 1. I want to be a camper at Camp Rockfish. 2. I will respect myself, my fellow campers, camp staff and camp property. 3. I will wear the proper safety gear at all times when instructed to do so. 4. I will use positive language to others. 5. I will refrain from negative physical behavior towards myself, my fellow campers, camp staff and camp property. 6. I understand that if I do not follow this behavior contract, I may have to leave camp early.Camper Signature: Date:Parent/Guardian Signature: Date: Photo & Video ReleaseCamper Name (print):I grant Rockfish Camp and Retreat Center(RC&RC), its representatives and employees the right to takephotographs of my camper and their property in connection with RC&RC activities and programs. I authorizeRockfish Camp and Retreat Center, its assigns and transferees to copyright, use and publish the same in printand/or electronically. I agree that Rockfish Camp and Retreat Center may use such photographs of my camperwith or without his/her name and for any lawful purpose, including for example such purposes as publicity,illustration, advertising and web content.I have read and understand the above.Parent/Guardian Signature: Date:Parent/Guardian Name (print):
  11. 11. Rockfish Camp & Retreat Center 226 Camp Rockfish Road Parkton, NC 28371 910-425-3529 Pick-Up Release Camper’s  Name: □ My camper will be leaving camp during normal check-out time. □ My camper will need to leave camp early due to an unchangeable scheduling conflict.Along with myself, the following person(s) are authorized to pick-up ___________________ from RockfishCamp and Retreat Center. camper nameName: Daytime Phone #:Address: Cell Phone #:Name: Daytime Phone #:Address: Cell Phone #:Name: Daytime Phone #:Address: Cell Phone #:I understand that Rockfish Camp and Retreat Center will only release my camper to the persons listed above inaddition  to  myself  after  I/they  display  a  valid  driver’s  license  with  a  name  that matches what I listed above.Name (print): Cell Phone #:Signature: Date:
  12. 12. Rockfish Camp & Retreat Center 226 Camp Rockfish Road Parkton, NC 28371 910-425-3529 Rockfish Camp Store Account Balance FormPlease tell your camper how much you have deposited in their camp store account and discuss with themhow they should spend it. On checkout day, the camp store will be open so that you and your child may useany remaining balance for store purchases, or you may choose to have any balance remaining deposited intoour Campership Fund.Please complete the following:My camper, _____________________________________________, is aware that his/her initial storebalance is: $_____________________.Please allow any remaining store balance to be:____ Donated to Camp Rockfish’s Campership Fund.____ Spent in the camp store at checkout.Parent’s Printed Name: ____________________________________________________________________Parent’s Signature: _________________________________________ Date: ________________________ If you have a particular concern regarding the distribution of your camp store balance, please contact our office manager. (For office use only) Store Balance: _______________ Donation to Campership Fund: _________________ Clerk: ________________ Rockfish Camp & Retreat Center is a ministry of the NC Methodist Camp & Retreat Ministries, Inc., which is an independent 501(c)(3) nonprofit organization, responsible  for  it’s  own  debts  and  obligations.    We  are  related  by faith to the NC Conference of the United Methodist Church. Tax ID# 56-2138935
  13. 13. Stay in touch this summer with One-Way Camper Email!We  are  excited  to  tell  you  about  our  partnership  with!    Bunk1’s  secure,  easy   to use, summer website services let you stay in touch with your camper all summer! GET STARTED TODAYTo set up a new account and visit our Online Community:1. Go to our website at and  click  “Summer  Camp”  (left  side)2. Click  the  flashing  “Camper  Email”  button *3. Click  “Register  Now”4. Enter your Pre-Approved Registration Code: 1210168RF5. Fill out all the required information6. Purchase Bunk Note credits (you will need a credit card)7. Send an email to your camper!* If you cannot find this button, go to instead and continue on to the nextstep** For your camper’s  safety,  please  do  not  share  the Pre-Approved Registration code above.FREQUENTLY ASKED QUESTIONSHow do I send a Bunk Note (one-way – be with your kids! Bunk Note credits costemail) to my camper? $1 each and are purchased in packs ofFollow the instructions above except, after various sizes.registering, simply sign in and click on theBunk  Notes  button.    Enter  your  camper’s   Can other relatives use these services?name, select the correct cabin, type your Certainly. Once you have set up yourmessage,  and  hit  the  “Send”  button. account, you will be able to invite other people to access these services.Why do I have to pay to send Bunk Notes(one-way email)? What do I do if I lost my username andEach morning, the Bunk Notes system password?bundles and sorts the messages for us to You can get it online by going toprint out and distribute to campers. It also and clicking on the linkprotects us from computer viruses and "Lost Your Password?" (to the left of theallows us to easily manage these emails. page below the sign in button). You willYour payment helps us cover the cost of the receive an email with your username andsystem, paper, ink, and labor and, more password within a few minutes.importantly, frees us to do what we do best QUESTIONS OR PROBLEMS?Please call Bunk1 at 1-800-216-9472 or go to