2018 Pine Cove Application

Please fill out the application completely by Friday, June 8, 2018. Once you begin the application, you will have to complete it in one sitting.

Camper Profile
Name of Camper: *
Name of Camper:
Gender: *
Birthday: *
Birthday:
Parent/Guardian Name: *
Parent/Guardian Name:
While at camp, your child will be in a group with several other campers of similar age. They will be supervised by a well trained, college-age counselor who has been selected for his or her maturity, integrity, sensitivity, and spiritual commitment to Jesus Christ. Your cooperation in completing this form will help your child’s counselor prepare to provide the needed encouragement and opportunities to make this camping experience easy, meaningful, and as productive as possible.
Will camper have a birthday while at camp? *
If so, birth date:
If so, birth date:
Has your camper been to camp before? *
If not, has your camper ever been away from home alone for two or more days?
Are both parents living? *
Camper lives with: *
Does camper have brothers or sisters? *
Check all that apply: *
Camper Health Form
Name of group your camper is coming with to Pine Cove: MERCY STREET The purpose of this health form is to assist Pine Cove Health Care Staff in identifying appropriate care. The information in this form will only be available to staff who will be working with your camper. This health form is required for camp attendance and must be completed by the camper’s parent/guardian.
Camper Name: *
Camper Name:
Parent/Guardian Name: *
Parent/Guardian Name:
Home Phone *
Home Phone
Cell Phone *
Cell Phone
Work Phone
Work Phone
Home Address: *
Home Address:
Date of Birth: *
Date of Birth:
Ethnic Background: *
Are both parents living? *
Camper lives with: *
Physician Information
Name: *
Name:
Phone: *
Phone:
Medicaid/Insurance Information
Emergency Contact Information
If Parent/Guardian is not available, please list two Emergency contacts.
Emergency Contact #1 *
Emergency Contact #1
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Emergency Contact #2 *
Emergency Contact #2
Home Phone
Home Phone
Cell Phone
Cell Phone
Work Phone
Work Phone
Immunizations
(Month and year)
Allergies *
Pine Cove is NOT peanut free.
(Include plant, animal, etc.)
Medical Concerns
Does your child have any of the following? (Check all that apply.) *
Medication *
Please list ALL prescription medication, over-the-counter and non-prescription drugs taken routinely. Fill in the blanks completely. Bring enough medication to last all week. Empty bottles will be returned to your camper. ALL DRUGS MUST REMAIN IN THE ORIGINAL CONTAINER. ALL PRESCRIPTION MEDICATIONS MUST BE IN A PHARMACY-LABELED CONTAINER WITH THE CAMPER’S NAME ON IT. LOOSE PILLS AND SAMPLES WILL NOT BE ACCEPTED.
Must be given at:
Must be given at:
Must be given at:
Parent/Guardian Authorization
The information given in this form is complete and accurate to the best of my knowledge. I hereby give my permission for my camper to participate in all camp activities. 1. I hereby give my permission for Pine Cove to use or disclose Protected Health Information (PHI) to necessary staff and any volunteer or paid health care professional or facility for diagnosis, treatment, health care needs, emergency medical care or coverage information for my camper as described on the enclosed Notice of Privacy Practices from Pine Cove, Inc. 2. I hereby give my permission to licensed Pine Cove medical/nursing staff, volunteer physicians and volunteer licensed medical/nursing staff to administer prescribed medication, provide health care, and seek emergency medical care. I hereby give my permission to Pine Cove to provide or seek transportation to medical facilitates for my camper. In case of emergency where I can’t be contacted, I hereby give permission to the physician selected by Pine Cove to secure and administer proper treatment, hospitalize, order injections, order anesthesia and/or surgery for my camper. 3. I HEREBY GIVE MY PERMISSION FOR LICENSED PINE COVE MEDICAL/NURSING STAFF TO ADMINISTER OVER-THE-COUNTER MEDICATIONS TO MY CAMPER AS NEEDED. 4. I understand that the Nurse Manager and/or the Camp Director reserves the right to send home a camper whose medical condition becomes unmanageable and/or places the camper or Pine Cove at risk in the Camp environment. 5. Camping standards DO require that each camper have a physical exam by a Physician, Nurse Practitioner, or Physician’s Assistant within 24 months (2 years) of attending camp (i.e. campers who will attend August 2018 must have a physical exam between September 2016 and August 2018). I, the parent/guardian of this camper hereby certify that he/she has met the requirement of a physical exam conducted by a Physician, Nurse Practitioner, or Physician’s Assistant within 24 months (2 years) of attending summer camp in 2018 OR will complete this requirement prior to his/her attendance at Pine Cove. I understand this stipulation is a requirement of Pine Cove and is not optional. My camper has had a physical exam with 24 months of his/her attendance at Pine Cove OR will have one prior to participation for the summer of 2018. THIS PHYSICAL EXAM IS REQUIRED FOR ATTENDANCE. 6. I agree to make Pine Cove aware of all known medical issues regarding my camper’s health and will update this form with additional issues that may occur between now and the start of camp. 7. I agree and understand that Pine Cove’s Supplemental Camper Insurance is a limited offering. The maximum amount is $2,500 for accidents and $750 for illness. My insurance information will be provided for amounts that exceed this offering.
Date: *
Date:
Release and Covenant Camper Agreement
Dear Parents and Guardians, We at Pine Cove, Inc. (“Pine Cove”) want to inform you of our safety precautions at camp. We feel that we have hired competent and knowledgeable staff. Nonetheless, your camper will be required by our staff to wear safety equipment for any activities requiring protective gear. Even with safety equipment, we at Pine Cove want you to realize that any outdoor camping and recreational activity has inherent dangers that no amount of care, caution, instruction or expertise can eliminate. I hereby affirm that I have been advised of and understand the risks of camping and recreational activities at Pine Cove and that such activities involve dangers and risks and I accept those dangers and risks knowingly and willingly for my camper. I understand that pictures and videos, and audio recordings are taken at camp. I hereby give permission for the use of such pictures, videos, and audio recordings of my camper for the promotion of Pine Cove. In addition, I give permission for my camper to be transported in vehicles for camp approved transportation and activities at Pine Cove and other locations. I understand that the terms herein are contractual and binding and not mere recitals. In signing this document, I hereby certify that I give permission for my camper to participate in the camping and recreational program of Pine Cove. I understand that the terms herein and my agreement to them applies for all of the calendar year of 2018 and all events occurring in 2018. I have signed this document as my own free act and in consideration of the agreement by Pine Cove to accept my camper for 2018. BY EXECUTION OF THIS DOCUMENT, I KNOWINGLY AND WILLINGLY RELEASE PINE COVE, THE STAFF, THE BOARD OF DIRECTORS, AND ALL OTHERS ACTING FOR OR ON BEHALF OF PINE COVE FROM ALL LIABILITY WHATSOEVER, FOR PERSONAL INJURY, OR INJURIES TO PROPERTY, REAL OR PERSONAL, CAUSED BY, OR ARISING OUT OF CAMPING AND OTHER ACTIVITIES SPONSORED BY PINE COVE.
Camper Name: *
Camper Name:
Date: *
Date:
Camp Expectations
Parents please read carefully: We are excited that you are interested in sending your child to Pine Cove Christian Camp with Mercy Street this summer. We are thankful that we have this opportunity and believe that it will be a week that will change their life. However, camp is not a right; it is a privilege to attend and there are guidelines so that all of the kids will have a safe and enjoyable experience. Fighting and disrespecting others is not tolerated at camp, so if a child is displaying this kind of continuous behavior prior to applying or during the application process they will not be allowed to attend. Camp is open for students who just completed their 3rd, 4th, 5th, 6th, 7th and 8th grade year of school and participate in a Mercy Street program. Applications are due by Friday, June 8, 2018 along with a $30 deposit. At the time the application is received it will be reviewed and you will be notified by July 1 as to whether or not your child has been accepted to attend camp. If your child is not accepted the $30 deposit will be returned. If your child is accepted they will need to attend 1 work day. Here are our general expectations: We only use encouraging language. This means cussing, scoring, and insulting are not allowed. We respect everyone at camp. This means no one is to be treated unkindly. We listen and follow instructions of adults. This means when an adult tells you to do something you will do it immediately. We clean up after ourselves. This means at dinner, in the cabin, during all the activities you are expected to clean up your mess. We stay with our group. There is no wandering off. You must be with the group at all times, unless you have permission from an adult to be somewhere else. When it is time to rest, it is time to rest. This means that when someone tells you it is time to go to bed you will go to bed. No questions asked. CONSEQUENCES Green Zone - Warning Blue Zone – Time Out – Time away from activity, talk with counselor Red Zone – Loss of Activity, free time or meal, talk with counselor Fire Zone – Time with head counselor (Mercy Street Staff) By signing this document, you acknowledge these expectations and understand the consequences. You understand that continued disobedience will result in removal from camp.
Date: *
Date:
Date: *
Date: