KIDDO  CAMP  PACKING  LIST  

WHAT  TO  PACK  IN  22 GALLON (or smaller) Plastic tub with lid -- LABEL with your child's first and last name please!!

WHAT  TO  BRING  • Sleeping bag, or twin sheets and cover• Pillow and pillow case• Shorts/T-shirts• Tennis shoes/water shoes/• SEVERAL PAIRS OF SOCKS REQUIRED• Swim suit (girls - one-piece only)/swim trunks (multiple pairs recommended for

guys -- LABEL!!)• Light jacket and raincoat• Brush or comb• Toothbrush and toothpaste• Soap and shampoo• Towels and wash cloths• Flashlight and batteries• Two 30- gallon trash bags• Sunscreen• Insect repellent• Creek walkin’ shoes - Bring an old pair of shoes that you can secure to wear to

go “creeking”. They will be wet!• 5th graders - 1 pair of long pants for special activity

LABEL ALL ITEMS WITH FIRST AND LAST NAME!

Medications needed-- all meds both prescription and over the counter must be checked in to nurse and medicine form completed by parent. Inhalers and epipens will be with the child's counselor at all times.

WHAT  NOT  TO  BRING v No electronics allowed! Campers are not allowed to use cell phones, etc.

v No food or snacks can be brought or kept in cabins. If food allergies or special food needs exist, please see camp staff to make needed arrangements.

v No shaving cream/ water balloons,etc. etc. etc. allowed

v Clothing should be modest and in good taste. Shirts should cover tummies and backs.

v No flip flops except in the shower

v NO BIBLES NEEDED due to Bibles being lost and/or damaged at camp. We will have scripture printed in camper books.

Parent/Guardian: please complete all Five Sections. If not applicable, please write “none” in section. All campers with parent/guardian must register at Nurses Station even if they do not take any prescription medications.

I hereby authorize Valley View Church personnel to administer medication to my child, _______________________________________, as listed below. I release the personnel from responsibility for any adverse reactions to this medication.

Parent/Guardian Signature: _____________________________Date: ___________

Phone (best contact): _________________ 2nd Phone Number: _______________

MEDICATION/STRENGTH DOSAGE/DIRECTIONS B L S Bd REASON PRESCRIBED

Concerta 18 mg 1 tablet daily x ADHD

Inhaler ____ Nurse ___ Counselor Given to:

Routine medication is only administered at breakfast (B), lunch (L), supper (S) and bedtime (Bd).

Please indicate your choice of time. Has this morning’s medicine been given? __Yes __No

Please list any allergies to drugs, food or other. De-scribe symptoms of a reaction and treatment course.

(I.e. recent illnesses, injuries, surgeries, breathing difficulties)

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

*Parents: Complete Top of Back Page

Epipen Sent: ___ yes ___ no

Given To: ___Nurse ___ Counselor

Ex.

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

Name of Medication/Strength Dosage Reason Date Time/Initials

/

/

/

/

/

/

/

/

/

/

/

/

My child, _____________________________, may take the following medications as needed based on package directions- ____Tylenol (acetaminophen) ____Other __________________________________________

____Advil (ibuprofen) ____Other __________________________________________

____Sinus/Allergy Meds ____Other __________________________________________

____Tums ____Other __________________________________________

____Topical Ointments (Neosporin, etc.)

Parent’s Initials: _____

Your permission is REQUIRED to give ANY meds to your child. Checkmark and your initials indicate your permission to

administer the following:

***********Below: For camp nurse use only.***********

Camper brought own over-the-counter medications: ____ yes ____ no

Nurse Check-In By: _______________

Nurse Med Labels By: ______________

Nurse Verified By: _________________

Team Color: _________________________

Counselor: __________________________

Revised 7.19.13

Authorization  for  Consent  to  Medical  Treatment  of  Minor  Child  

 

 I/we  hereby  authorize  the  adult  workers  of  Valley  View  Church  to  give  consent  for  all  medical  

and/or  surgical  treatment  that  may  be  required  for  our  child  while  in  Valley  View  Church  care.    I  

also  release  Valley  View  Church  and  its  employees,  agents,  and  volunteers  from  any  liability  in  the  

event  of  an  accident.  

 

Child’s  Full  Name  ___________________________________________________    

Date  of  birth    ___________________________________  

Child’s  Physician:_____________________________________________________________________  

Child’s  Allergies  ______________________________________________________________________  

Medications  child  is  taking:  ______________________________________________________________  

Important  medical  history  _______________________________________________________________  

Date  of  last  Tetanus  Immunization  __________________________  

 

Home  address  of  parent/guardian:  _______________________________________                            

             _______________________________________  

Parent/guardian  Telephone  #  :  ________________________        Cell  #  ___________________________  

 

Emergency  contact  (other  than  parent/guardian):  ___________________________________________  

Telephone:  _______________________________                                    Cell:  _____________________________  

Primary  Medical  Insurance  Carrier  _____________________________________________________  

Member’s  Name    ___________________________________________________________________  

ID#  _______________________________                                                Group  #  ____________________________  

 

 

Signature  of  parent/guardian(s)  ________________________________________________________  

Date  signed  ___________________________  

Signature  of  adult  witness  ____________________________________________________________  

YMCAofGreaterLouisville

545SouthSecondStreetLouisville,KY40202(P)5025879622

YMCACAMPPIOMINGO

GENERALRELEASEOFLIABILITYFORHIGHRISKACTIVITIES

2018

PLEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS! PARTICIPATION AGREEMENT/ASSUMPTION OF RISK & RELEASE: Please READ & SIGN this Statement. Incomplete forms will be returned. · Whereas, the undersigned (the “Applicant”) wishes to be accepted for participation in all camp activities including “High Risk” activities if scheduled,conducted by YMCA of Greater Louisville Camp Piomingo, and in consideration of YMCA of Greater Louisville Camp Piomingo action in allowing the Applicant to participate in such program. · The undersigned acknowledges that during the said activities that the Applicant isrequested to participate in, that certain risks and dangers may occur. These include but are not limited to the hazards of depending on other people and being at various heights (ground to 50’), accident or illness in remote places without medical facilities, the forces of nature and travel by air, train, boat, automobile or other conveyance. The undersigned further recognizes risks may also include loss or damage to personal property, physical or psychological damage and/or injury not excluding fatality due to accidents which may occur, including accidents resulting from this challenge course experience or other type of outdoor activities. I further understand that in participating in the activities I am requesting to participate in, I could be exposed to the elements of nature, including temperature extremes, and inclement weather. I further understand that medical treatment may be several minutes to hours away in the event of a medical emergency. · In consideration of and a part of payment for the right to participate in such a program and the services and food arranged for me by YMCA of Greater Louisville Camp Piomingo, its board of Management, Officers, Employees, Agents, and/or Associates I have and do hereby assume all the above risks and any other ordinary risk incidental to the nature of the program, including risks which are not specifically foreseeable, and will hold them harmless from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever, whether for bodily injury, property damage or loss or otherwise, which I now have or which may arise from or in connection with my program or participation in any other activities arranged for me by YMCA of Greater Louisville Camp Piomingo, its board of Management, Officers, Employees, Agents, and/or Associates, and their heirs, executors and administrators. The terms hereof and my signature on this document shall bind my heirs, representatives, executors, and administrators, successors, and assigns and for all members of my family, including any minors accompanying me. I also state that I am not

under, and will not be under the influence of any chemical substance including alcohol. I fully understand that any physical activity involves risk of injury. I also understand that my participation in the YMCA of Greater Louisville Camp Piomingo program is entirely voluntary and that I may excuse myself from participation if I so desire. · I hereby enroll in YMCA Camp Piomingo Programming. In signing this application, I certify that he/she is healthy and free of problems that could adversely affect his/her stay or that of other campers at YMCA Camp Piomingo. · I agree to pay the balance of camp fees on or before that fee is due. I understand that reserved spaces cannot be held without full payment. · I grant permission for the applicant to participate in all planned camp activities. My child has permission to leave the YMCA Camp Piomingo grounds with authorized Camp Staff in authorized Camp vehicles for scheduled trips and outings. I fully understand the inherent risks involved in activities my child will be choosing or has already chosen. I, the parent/guardian, accept all risks including those activities preliminary and subsequent to the chosen activities. · I hereby grant the YMCA Camp Piomingo and its agents full authority to take whatever actions they deem necessary regarding my child’s health and safety, and I fully release YMCA Camp Piomingo from any liability in connection there within. I understand that prudent attempts will be made to contact the undersigned immediately. I understand that there is no accident or medical insurance provided and that I will be responsible for payment of all medical and medication bills. Parents will be expected to pre-pay any medical office co-pays and for any prescriptions picked up for their child while at camp. · I understand that my child must comply with the camp’s rules and standards of conduct and that the organization may terminate my child’s participation in the camp program if he/she does not maintain these standards. · I authorize YMCA Camp Piomingo, without limitation or obligation, to use photographs, film footage or tape recordings which may include my child’s image or voice for purposes of promoting or interpreting YMCA Camp Piomingo programs and release the camp from any claim or liability to that use. · While YMCA Camp Piomingo will make every attempt to provide reasonable accommodations for mentally and physically challenged children, the camp will not accept children that are (1) of danger to themselves, (2) of danger to others, or (3) a disruption to the normal activities making it unreasonably difficult for other children to enjoy camp programs. Any of the above reasons will be grounds for dismissal from camp. A parent/guardian must discuss with the director any special conditions or circumstances involving their child. This must be done prior to registration so that we can advise you as to whether we can make a reasonable accommodation for your child. · YMCA Camp Piomingo is not responsible for lost, stolen or damaged personal articles. Name of Participant _______________________________ (Please Print) Signature of Parent or Guardian _______________________________ Date_____________

Signature of Witness ________________________________________Date_____________