2020 Camp Required forms

Camper name* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Age* This field is required.

How many years has this child attended Camp Wakonda?* This field is required.If first year, enter zero.

Years in Camp

Gender* This field is required.

Male

Female

Grade Fall 2020* This field is required.

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

Cabin mate request* This field is required.List none if no cabin mate requested

One, please

Dates of Attendance

June 7-12

June 14-19

June 21-26

July 5-10

July 12-17

July 19-24

July 26-July 31

August 2-7

Does this camper have any known allergies?* This field is required.

YESNO

List of allergies* This field is required.

Please list all food allergies

Please list all medication allergies

Please list all environmental allergies (insect stings, hay fever, etc.)

Please list all other allergies

Camper Diet* This field is required.

This camper eats a regular diet

This camper eats a vegetarian diet

This camper has special food needs

Please describe your camper's dietary needs* This field is required.

After reviewing the program and activities of Camp Wakonda, do you feel your camper can participate without restrictions?* This field is required.

YESNO

What restrictions or adaptations would you like to put in place?* This field is required.

Insurance

Is this camper covered by medical insurance?

Insurance company

Policy number

Subscriber

Insurance company phone number

Are this camper's immunizations up to date?* This field is required.

YESNO

Please check all that apply to your camper* This field is required.About your camper's general health

Has been hospitalized

Has been treated for attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)

Had surgery

Has been treated for emotional or behavioral difficulties or an eating disorder

Had recurrent/chronic illness

Has seen a professional to address mental or emotional health concerns during the last 12 months

Had a recent infectious disease

Has had a significant life event that continues to affect his or her life

Has had a recent injury

Has asthma/wheezing/shortness of breath

Has diabetes

Has seizures

Has headaches

Wears glasses, contacts or protective eyewear

Has experienced fainting or dizziness

Has passed out or had chest pain during exercise

Has had mononucleosis during the last 12 months

Has had problems with menstruation

Has had problems with falling asleep or sleepwalking

Has had back or joint problems

Has a history of bedwetting

Has had problems with diarrhea or constipation

Has any skin problems

None of the Above

Please explain your camper's health history for each checked box on previous page* This field is required.

Has your camper traveled outside the US in the past 9 months?* This field is required.

YESNO

Which countries?* This field is required.Please provide dates if you can

Help your counselor get to know you betterPlease fill this section out with your camper if you can. It's great to hear these answers in their own words.

Nickname or preferred name

Has this camper ever spent the night away from home before?

My favorite camp activities are

I really like to play

I'm really good at

I'd like to get better at

Some of my hobbies and interests are

One last thing we should know about you

Will your camper take any daily medications while attending camp?* This field is required.Medication is any substance a person takes to maintain and/or improve their health.

YESNO

Please describe all medication* This field is required.Remember to provide enoughmedication to last the entire week. All medication must be in its originalpackaging that identifies the prescribing physician (if a prescription drug),name of patient (must be prescribed to camper), name of medication, dosage andfrequency of administration.

Name of medication

Reason for taking

When given

Dosage given

How given

Name of medication

Reason for taking

When given

Dosage given

How given

Please check any medication your camper should NOT be given* This field is required.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.

Acetaminophen (Tylenol)

Phenylephrine decongestant (Sudafed PE)

Antihistamine/allergy medicine

Diphenhydramine antihistamine/allergy medication (Benadryl)

Sore throat spray

Lice shampoo or cream (Nix or Elimite)

Calamine lotion

Laxatives for constipation (Ex Lax)

Ibuprofen (Advil or Motrin)

Pseudoephedrine decongestant (Sudafed)

Guaifenesin cough syrup (Robitussin)

Dextromethorphan cough syrup (Robitussin DM)

Generic cough drops

Antibiotic cream

Aloe

Bismuthsubsalicylate for diarrhea (Pepto Bismol)

All medications listed may be given to my child

Parent/Guardian* This field is required.

First Name

Last Name

Address* This field is required.

Street Address

City

State

Zip Code

Country

Email* This field is required.

the_y@orymca.org

Primary phone number* This field is required.

Secondary phone numberoptional

Second Parent/Guardian(optional)

First Name

Last Name

Second Parent/Guardian phone number(optional)

Second Parent/Guardian secondary phone number(optional)

Emergency contact* This field is required.Other than Parents/Guardians

First Name

Last Name

Relationship to camper* This field is required.

Emergency phone number* This field is required.

Would you like to apply for additional Financial Assistance?* This field is required.

YESNO

Please tell us briefly about your circumstances* This field is required.

How much do you feel you can pay for your camper's week at camp?* This field is required.

Is this a foster child?* This field is required.

Yes

Does this child receive SNAP benefits?* This field is required.

Yes

Please provide your SNAP case number

Does this child receive TANF benefits?* This field is required.

Yes

Please provide your TANF case number

Primary household adult income based on* This field is required.

Yearly

Monthly

Twice a month

Every two weeks

Weekly

Primary household adult income* This field is required.Place a "0" in boxes that do not apply

Do you have a Social Security number?* This field is required.

Yes

Last 4 digits of Social Security number* This field is required.

Additional household members* This field is required.Please list all household members, regardless of income

Full name

Gross wages

Welfare child support, alimony

Pensions, retirement, social security

Other

Household member 1

Household member 2

Household member 3

Household member 4

Household member 5

Household member 1

Household member 2

Household member 3

Household member 4

Household member 5

Full name

Gross wages

Welfare child support, alimony

Pensions, retirement, social security

Other

Full name

Gross wages

Welfare child support, alimony

Pensions, retirement, social security

Other

Full name

Gross wages

Welfare child support, alimony

Pensions, retirement, social security

Other

Full name

Gross wages

Welfare child support, alimony

Pensions, retirement, social security

Other

Full name

Gross wages

Welfare child support, alimony

Pensions, retirement, social security

Other

Email* This field is required.

example@example.com

* This field is required.

USDA Nondiscrimination Statement* This field is required.

Immunization acknowledgement* This field is required.

Authorization for health care* This field is required.

Terms of Program Participation* This field is required.

Signature* This field is required.By providing this signature I hereby certify that all information provided is correct and true to the best of my knowledge.

Are you ready to have fun this summer? We are! In order for you to have a fun, exciting and safe summer, everyone needs to follow the same guidelines. Below is a list of the basic rules that you will need to follow while you’re at camp. Keep in mind that more specific rules will be talked about when you get here (mealtimes, bedtime, activities, etc.). Please read over all of these guidelines and make sure that you understand them. You will be expected to follow these guidelines upon arrival at YMCA Camp Wakonda. This form MUST be completed along with all required forms for your child to participate at Camp Wakonda. All forms MUST be turned in two weeks prior to your child’s attendance at camp.

WHILE AT CAMP WAKONDA:

I will be honest and respectful (of my peers, my camp staff, and myself).
I will follow directions and rules at camp.
I will not act violently toward any camper or staff member.
I will not steal or destroy property belonging to Camp Wakonda, other campers, or staff members.
I will not use/practice inappropriate conduct and language.
I will stay within camp boundaries.
I will do my best to HAVE FUN!!!

Camp Behavior Policy:

Step 1: Inappropriate behavior is discussed with the camper by their counselor and/or program director, helping the camper to understand the rules and take responsibility for changing the behavior. The 4 core values of the YMCA, the ‘I’m Third’ motto, appropriate behavior as well as consequences are discussed.

Step 2: A call home is made by senior staff to discuss the behavior and gain insight. The camper will meet with the program director/camp director to discuss their actions, the negative impact these actions have, appropriate behavior and consequences should inappropriate behavior continue. Camper will call home.

Step 3: The camp director will inform parents that their camper cannot remain at camp. A parent or guardian will be asked to pick up the camper from Camp Wakonda as soon as possible. Parent or guardian is responsible for pick up/transportation of camper.

There are a few situations that will automatically result in a child being sent home. Those situations include, but are not limited to; causing physical injury to another camper, intentionally damaging another campers belongings or camp property, and violating other items on this Camper Conduct Policy.

Camper Agreement* This field is required.

Parent Agreement* This field is required.

2020 Camp Required forms