FREE SUMMER CAMP FOR MILITARY KIDS The National Military Family Association’s Operation Purple® camps offer a free week of fun for military kids with parents SIGN UP TO ATTEND who have been, are currently, THE CAMP IN YOUR AREA. or will be deployed. Visit www.MilitaryFamily.orgCamp Location: Dates: for registration information, locations, and dates. 4-H Rural Life Center August 1 - 7, 2010 Halifax, NC Ages While At Camp: Ages 10 - 15 Co-ed ® A program of the National Military Family Association
Operation Purple® Camp The 4-H Rural Life Center is located in rural Halifax, North Carolina wherethe “Spirit of Independence Was Born” at 13763 Highway 903. The 4-H Centerwas originally built as the county home around 1923, but was taken over by theHalifax County Cooperative Extension Service around 1985 and turned into the4-H Camp. This was a perfect fit as the dormitory building laid out exactly theway a camp needed with a wing for boys and a wing for girls with a commonarea, dining room, and kitchen between. Each wing has small individual roomswith two to four bunk beds as well as two bathrooms. The heated and airconditioned facilities makes summer camp very comfortable for a home awayfrom home. Our facility is located on over 345 acres and has many amenitieswhich include the main camp building, a Rosenwald School, an antiqueagricultural equipment museum, an outside basketball court, volleyball court, andsoccer / softball field. We also have an archery range, a high and low ropescourse, and a climbing wall along with many hiking trails and ten canoes for usewith some of our field trips. This year the 4-H Rural Life Center in partnership with the National MilitaryFamily Association, Inc. will be offering a residential Operation Purple® Campto children of military families. Deployment affects everyone in the family, notjust the service member. Here at camp, we feel the real heroes are the childrenas we feel “kids serve too” and we are proud and honored to offer a week ofcamp to this extremely special group of campers. This is going to be a week youdo not want to miss. The following information should help you with some of the questions youmay have as well as let you know what we will be accomplishing this week. Atthe end of this is the Operation Purple® Camper Summer Camp Applicationwhich you will need to fill out and sign and mail back in to us here at the 4-HRural Life Center. For more information you can contact us here at the 4-HCenter at 252-583-1821 or call the Cooperative Extension Service at 252-583-5161. Our mailing address is as follows: 4-H Rural Life Center - P.O. Box 37- Halifax, NC 27839 and we are located at physical address for shipping:13763 Hwy. 903 - Halifax, NC 27839. Mail or packages may be sent to theseaddresses for campers, but we do not have email available for camper use.Please remember it takes time for mail to arrive here. The telephone is foremergency uses only.
General InformationArrival / DepartureCheck in for camp will be from 4:00 pm until 5:00 pm on Sunday, August 1, 2010.Please do not arrive early as the counselors will be in the process of making surethings are ready for your arrival prior to this time. If you need to arrive at adifferent time, please call and let us know what arrangements need to be madeMonday through Friday from 9:00 am until 4:00 pm. Departure will be at 9:00 amon Saturday, August 7, 2010. It is important to adhere to this schedule.Dinner will be served to campers on Sunday evening after check in.CostThis camp is provided free of charge to all eligible participants and will be paid infull by the National Military Family Association, Inc. Operation Purple Camp.What to Bring to CampFitted and Flat Sheet with Blanket for Single Size Bed or a Sleeping BagPillow with Pillowcase5 to 6 Towels and WashclothsToiletries (Toothbrush, Toothpaste, Soap, Deodorant, Shampoo, etc.)2 to 3 SwimsuitsPlenty of Appropriate Summer Clothing (T-shirts, Long and Short Pants, Jacket)1 Pair of Old Shoes or Water ShoesTennis ShoesRain GearInsect RepellantSunscreenCamera (Optional)Spending Money (Just for Souvenirs While on Field Trips – No More than $25)(Campers will be responsible for their own spending money as all mealsand tickets will be paid for already.)What Not to Bring to CampExcessive Amounts of MoneyExcessive Food, Drinks, and Snacks (Snacks will be Provided)Radios, Televisions, Stereos, Cell Phones, etc.No Expensive Items, Especially JewelryNo Weapons or Controlled Substances of Any Kind(Campers will be responsible for what they bring and neither the 4-H RuralLife Center nor the staff will be responsible for any losses.)Room Assignments While At CampEach room has either two or four single size bunk beds. We will make roomassignments as campers arrive and will try to accommodate any request possiblefor roommates. This is also something that can change during the week at thecamper’s requests, or as needed by staff if curfews are not adhered to at night.Please attach a note to the application to let us know if you have a roommatepreference ahead of time. Also, if coming with siblings of the same gender,attach a note to let us know if you would like to share a room with them or not.
This Week’s Schedule of Activities: Our goal is to make this week the most meaningful and memorableadventure that our campers ever have. We would like for them to come awayfrom camp learning many new skills, making new friends, learning somethingabout military life, and having had the most fun possible. In order to accomplishthese goals, we have planned a wide variety of activities and field trips that allcampers should find enjoyable. As for our field trips, we will be going to Water Country, USA inWilliamsburg, VA for a day at the water park and possibly visit Fort Eustis aswell. Campers will enjoy giant slides, lazy rivers, water tubes, and many otheractivities while at Water Country. Lifeguards will be on duty and knowing how toswim is not required. We also plan to take another day long field trip to the NCZoological Park in Asheboro, NC. Here campers will be able to learn about manydifferent animal species and see them in their natural habitats as they range inopen prairies in environments similar to the continent they actually come from.Both of these trips are around two hours from camp and we will go and come onair conditioned charter buses with bathrooms. We may also take some local field trips which may include a visit intoHistoric Halifax where campers will be able to tour a period in time from the1700’s. Halifax, NC is where the Halifax Resolves was signed on April 12, 1776which made NC the first of the 13 English Colonies to declare it’s independencefrom Great Britain which led to the signing of the Declaration of Independence forthe United States from England on July 4, 1776. We also plan to visit our localaquatic center where campers will have the opportunity to spend time swimmingand learning about aquatics. If time permits, we may also take a field trip to LakeGaston where we may have the opportunity to canoe and possibly even try ourhand at fishing. We may even do some bowling one day and possibly go to alocal theater for a private showing of a movie or show. Any movies we see willbe rated either G, PG, or PG-13. Other activities this week may include crafts, camp songs, astronomy,sports, team building through the use of our challenge courses and climbing wall,camp fires, cookouts, and many military opportunities to see how the camper’sfamily members work and function each day. As the military will be a big part ofour camp, we expect to have lots of activities geared towards this way of life. Itwill be difficult to list these different activities as things can change right up to thelast minute with the military depending on their status at any given time.Parachute jumpers, flyovers, rides in hummers and tanks are all possibleactivities along with many others. We will also participate in a community serviceproject to learn how we can all give back to society no matter what age. Normally, we should begin our day by rising around 7:00 am and havingbreakfast around 8:00 am. Daily activities should begin by 9:00 am with luncharound noon and dinner around 6:00 pm. Evening activities will conclude mostevenings by 10:00 pm with lights out by 10:30 pm. Showers will usually be takenin the evenings prior to bedtime. We will also take time each evening to reflecton the day and talk about anything the campers feels are important to them, anddo some journaling. This schedule is certainly going to be flexible and maychange as we have many activities scheduled for every day of this week. By the end of this week, campers will have made new friends, learnedmany new skills, and discovered many new aspects of military life they nevernew existed and should leave camp with a fresh outlook letting them know theyare heroes because “kids serve too”.
4-H Rural Life Center Attach Photo Here Operation Purple® Camper Summer Camp ApplicationCamper Name____________________________________ Birth Date____________ Age at Camp_______ Gender____ Last First MiddleHome Address_____________________________________________________County_______________ Grade______ Street City State ZipNickname to be used at camp if different from above _____________________ Email Address _____________________Parent or Guardian: ___________________________ Second Parent or Guardian: _____________________________Address: ___________________________________ Address: ____________________________________________ _____________________________ ____________________________________Home Phone / Cell / Work_______________________ Home Phone / Cell / Work______________________________Emergency Contact (Other than Parent/Guardian) Name / Relationship_______________________________ Phone___________________Health HistoryThe following information must be filled in by the parent/guardian. Update required annually. Health exam must becompleted by approved licensed medical personnel within 12 months of participation. The intent of this information is toprovide camp health care personnel the background to provide appropriate care. Keep a copy of the completed form foryour records. Any changes to this form should be provided to camp health personnel upon participant’s arrival in camp.Provide complete information so that the camp can be aware of your needs.MEDICATIONSPlease list ALL medications, even over-the-counter or nonprescription drugs, including Tylenol, Pepto-Bismol, Benadryl, etc.that may be taken. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle thatidentifies the prescribing physician (if prescription drug), the name of medication, the dosage, and the frequency ofadministration. Please turn over all medications to the camp health personnel while attending camp. This person takes NO medications on a routine basis This person takes medications as follows: Med#1_________________________ Reason _____________ Dosage__________ Time taken ______________ Med#2_________________________ Reason _____________ Dosage__________ Time taken ______________ Med#3_________________________ Reason _____________ Dosage__________ Time taken ______________ Med#4_________________________ Reason _____________ Dosage__________ Time taken ______________This person may take the following medications as needed: Aspirin Tylenol Ibuprofen Benadryl Pepto-Bismol Other_____________________General Questions (Explain “yes” answers.)Has/does the participant: Yes No Yes No 1. Had any recent injury, illness or infectious disease? 13. Ever had high blood pressure? 2. Have a chronic or recurring illness/condition? 14. Ever been diagnosed with a heart murmur? 3. Ever been hospitalized? 15. Ever had back problems? 4. Ever had surgery? 16. Ever had joint problems? 5. Have frequent headaches? 17. Have any skin problems? 6. Ever had a head injury? 18. Have diabetes? 7. Ever been knocked unconscious? 19. Have asthma? 8. Wear glasses, contacts or protective eye wear? 20. Had mononucleosis in the past 12 months? 9. Ever had frequent ear infections? 21. Have problems sleepwalking?10. Ever been dizzy/passed out during or after exercise? 22. Have a history of bed wetting?11. Ever had seizures 23. Ever had an eating disorder?12. Ever had chest pain during or after exercise? 24. Ever been found to have any mental disorder?Please explain “yes” answers, noting the number of the questions.___________________________________________________________________________________________________________________________
Known allergies to foods, drugs, insect stings or bites, etc.: __________________________________________________Special medical, mental, psychological, dietary or physical Family Physician Name: _________________________concerns or restrictions: __________________________ Address:_________________ Telephone: ___________Which of the following has the participant had? Please give dates of immunization for: (Attach Shot Record) Vaccine: Dates: Mo/Yr Mo/Yr Mo/Yr Mo/Yr Measles DTP ____ ____ ____ ____ Chicken pox TD (tetanus/diphtheria) ____ ____ ____ ____ German measles Tetanus ____ ____ ____ ____ Mumps Polio ____ ____ ____ ____ Hepatitis A MMR ____ ____ Hepatitis B or Measles ____ ____ Hepatitis C or Mumps ____ ____TB Mantoux Test Date of last test________ or Rubella ____ ____Result: Positive Negative Haemophilus influenza ____ ____ ____ ____Family Dentist Name: ____________________________ Hepatitis B ____ ____ ____Address:____________________Telephone:__________ Varicella (chicken pox) ____ ____ ____Health Care Recommendations by Licensed Medical PersonnelI examined (camper name) _____________________ on _____________. BP_____ Wt _____ Ht______In my opinion, the above applicant is is not able to participate in an active camp program and all activities.Restrictions/Recommendations:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Signature of Licensed Medical Personnel _______________________________________________Date____________Printed__________________________________________Title_______________________________________________Address_________________________________________Phone_____________________________________________ Screening Record: For camp use only Date___________ Time_________ Meds received____________________________________________________________________________________ Updates/additions to Health History___________________________________________________________________ Current Health needs identified_______________________________________________________________________ Screened by____________________________ Custody Release: You may be asked to produce photo ID at check-out. This is for your child’s safety. Please be aware of this policy before picking up your child. I hereby give permission for my child, _______________________________, to be allowed to leave the 4-H Camp at the conclusion of the camping program. My child will be released into the custody of _____________________________________________________________________________________________. (Names of All Individuals authorized to pick up your child) If it is necessary for my child to leave the Camp before the end of the program due to illness, injury, or behavioral issues, and I can not be reached, I hereby give permission for my child to be released into the custody of______________________________________________________________________________________________. (Emergency contacts or other individuals authorized to pick up your child) For Camp Use Only: Camper picked up by _____________________________ Staff Signature__________________.
In the event that the camper needs minor medical care from 4-H personnel or more significant medical care from a qualifiedhealth care provider, including in rare cases possible hospitalization and or surgery, the parent / guardian is asked to readand sign the informed consent form as follows:I authorize the 4-H Rural Life Center personnel to do any acts which may be necessary or proper to provide for the healthcare of the above named camper including, but not limited to, the power to provide for such health care at any hospital orother institution, or the employing of any physician, dentist, nurse, or other person for such health care and to consent to andauthorize any health care, including administration of anesthesia, X-ray examination, performance of operations, and otherprocedures by physicians, dentist, and other medical personnel except the withholding or withdrawal of life sustainingprocedures.It may be necessary to bill the family’s insurance company. Please provide the following information:Insurance Company: _________________________________ Address: _________________________________ _________________________________Insurance Policy #: __________________________________Telephone Number: __________________________________Field Trip Permission – The above name camper has permission to go on any field trip(s) planned as part of the summer4-H program.Photograph Release – I, the undersigned, hereby authorize the 4-H Rural Life Center to use photographs, videos, or otherrecordings which I have voluntarily allowed to be taken by representatives. I understand that such use may include, butshall not be limited to, publications, slide shows, displays, or videos. I hereby waive any right to which I or my heirs mayotherwise be entitled by law to assert against the 4-H Center on account of injury sustained by my reputation arising fromcauses of action including, but not limited to libel, slander, defamation of character and invasion of privacy as a result ofsuch publications and hereby release the 4-H Rural Life Center and it’s personnel from any liability on account of suchinjury.4-H Code of Conduct and Disciplinary Procedure – Please refer to the following internet link to obtain a copy andunderstanding of this policy and have the camper sign below after reading it stating he / she agrees to be bound by it.http://www.nc4h.org/centers/4hcodeofconduct.pdfCamper’s Personal Property – Neither the 4-H Center nor the camp staff shall be responsible for the loss of or damage tothe personal property of the camper. Campers should not bring electronic devices or any other expensive items.Damage – Parents will be responsible for and pay for any damage done by the camper either alone or with others.No One is to leave camp without the prior permission of the Camp Director.Telephone usage is for authorized emergencies only and should only be used with the permission of the Camp Director. **Cell phones are not permitted at camp without prior permission of the Camp Director.**I have read and understand this entire form and agree that to the best of my knowledge it is true and correct and tobe bound by all contained within.Camper Name (Please Print): ___________________ STATE OF ________________, COUNTY OF _______________Camper Signature: __________________ On this _________day of _________,20___, _______________,Date: _______________ personally appeared before me the said named,____________, to me known and known to me to be the person described inParent / Guardian Name (Please Print): ___________________ and who executed the foregoing instrument and he (or she)Parent / Guardian Signature: _________________ acknowledged that he (or she) executed the same and beingDate: _______________ duly sworn by me, made oath that the statements in the foregoing instrument are true. My commission expires __________________,20____ ____________________________________(OFFICIAL SEAL) Notary Public ____________________________________Please fill out completely and sign this application and mail it to: 4-H Rural Life Center P.O. Box 37 Halifax, NC 27839 252-583-1821