AnyTown 2013 Delegate Application Form June 10-15, 2013

Transcription

1 AnyTown 2013 Delegate Application Form June 10-15, 2013 Application packets due May 20 th Name: Home Phone: Address: City: State: Zip: High School: Cell Phone: Grade Level for Next ( ) School Year (circle one): 10 th 11 th 12 th Date of Birth / / Age right now (requested - this is primarily how we will contact you): To ensure diversity at Camp AnyTown please answer the following: Sex: (please check one) Male: Female: Race: (be specific) American Indian: Asian: Black/African American: Middle Eastern: Latino(a)/Hispanic: Pacific Islander: White/European American: Other: (please specify): Please check the following that best describes your religion: Protestant/Christian: Muslim: Buddhist: Catholic/Christian: Jewish: Hindu: Sikh: Other: (please specify): Do you require special accommodations for diet or physical accessibility? No: Yes: (please specify): Do you have a chronic illness/condition which would interfere with or limit your ability to live safely in an isolated rural wooded area? No: Yes: (please specify): My t-shirt size is (Circle one): S M L XL XXL

2 We Open Minds. The application fee is $25. This holds your spot for AnyTown. The cost for AnyTown is a nominal fee $300 which goes towards transportation to camp, food and lodging costs. ***If you are unable to pay the application fee and/or the AnyTown fee there are scholarships available. If you are requesting a scholarship, please answer the following questions (this information is kept confidential): Are you eligible for free and reduced lunch? Yes: No: Briefly explain why you are requesting a scholarship: From whom did you hear about this program? Participation at AnyTown is limited and we may not be able to accept all students that apply. On separate sheet of paper, answer the following questions so that we may learn a little more about you and your interest in AnyTown Typing is preferred. LEGIBLE printing will be accepted. 1) If you could eliminate your school of one social ill, what would you eliminate and why? 2) Why do you want to be an AnyTown delegate? What do you hope to learn from the experience? PARENT(S)/GUARDIAN SIGNATURE: I give permission for my child/ward to apply for AnyTown 2013, which will be held June 10-15, I have read the application and provided materials and willingly want my child to participate. I also understand they need to be present for the entire week at AnyTown in order to attend. Signature: Date: Please return entire packet by May 20, Please mail or fax to: Building Bridges Youth Opportunity Center 1704 Charlotte Pike, Ste. 200 Nashville, TN Fax: Questions? Call ext Or Tasha Fletcher at tfletcher@oasiscenter.org

3 AnyTown 2013 RELEASE, HOLD HARMLESS, AND PHOTOGRAHPY RELEASE This form will be kept on file and covers all CommunityNashville events from 1/01/13-12/31/13 I fully understand that my child s (minor) or ward s participation in a Building Bridges/Oasis event or program (hereinafter Event ) exposes him/her to risks inherent in camping and youth events. I hereby acknowledge that I am voluntarily allowing my child/ward to participate in this Event and agree to assume any such risks. In consideration for being permitted to participate in the Event, I hereby agree, for my child/ward, that I shall hold harmless Building Bridges/Oasis from any and all claims, demands, actions, or suits arising out of or in connection with my child s/ward s participation in Event. I give permission to authorize personnel to carry out such emergency treatment as may be necessary for my child/ward, and also permit such treatment to be carried out at, and by the local hospital(s) for my child/ward in the event of an emergency. I agree to permit Building Bridges/Oasis staff and other guests to take photographs and/or videotape during Building Bridges/Oasis Events without further recourse. I understand that such photographic images, video, or audio recording of my child/ward may be used for promotional purposes. Minor s Name School Age Parent/Guardian Consent I have read this release, hold harmless agreement and photography release, and fully understand its contents. As parent/guardian of this minor, permission is hereby granted for him/her to participate in Building Bridges/Oasis Events and have any photographs or videotapes of activities of event with images of my child/ward. Parent/Legal Guardian Signature Print Date

4 AnyTown 2013 Health Information USE: This health history is to be completed and signed by parent/guardian of minor members or by adult volunteers themselves. The information should be reviewed by parent /guardian or adult member before every trip to ensure that the information has not changed. The camp nurse/volunteer trained in first aid should ensure that the information on this form remains as confidential as possible. Full Name: DOB: Age: Parent/Guardian Full Name: Home Phone: address of adult: Cell Phone: Home Address: Other contact number: In case of Emergency, notify (adult other than parent/guardian): Day phone: Evening phone: Insurance information, please complete the following: Carrier: ID number: Group Number: Member services phone number: Address: Section I: Current Medication Is the participant currently taking any medication? Please list below. You may also use this space to indicate any over the counter medications that your student is allowed to take if necessary. All medication will be administered by an adult volunteer certified in first aid. Name of medication/indication Date prescribed Dosage Other comments Date of last health exam: Since last exam, has participant had: YES NO Any injury or medical attention? An illness lasting more than 5 days? Any exposure to a contagious disease? Treatment in a hospital, outpatient clinic or emergency room? Any restrictions on physical activities? Please explain any yes answers:

5 Section II: Illness and injuries (check all that apply and explain below) Chronic or recurring illness Ear infection Heart defect/disease Bleeding/clotting disorders Hypertension Asthma Seizures Diabetes Other (explain): Section III: Allergies (check all that apply and specify nature of allergic reaction): Animals: Plants: Bugs/insects: Other- describe: Section IV: Other health conditions (check all that apply and explain in open space below) Emotional Motion sickness Dietary restrictions disturbances Hearing impairment Glasses/contacts Fainting Nosebleeds Anemia Menstrual cramps Sleep disturbances Other (specify): FOR PARTICIPANTS 18 AND UNDER This health history is complete and accurate. I know of no reason(s), other than the information indicated on this form, why my student should not participate in prescribed activities except as noted. If this information changes prior to camp, I will notify Building Bridges/Oasis Center in writing. I understand this information will remain confidential to the designated persons trained in first aid or emergency personnel as needed. I herby give permission to the adults in charge to provide health care, administer prescribed medications and seek emergency medical treatment. I give permission to the adults in charge to arrange necessary related transportation for my child. Parent/Guardian Signature Date FOR ADULT PARTICIPANTS This health history is complete and accurate. I am able to participate in prescribed activities except as noted. If this information changes prior to camp, I will notify Building Bridges/Oasis Center in writing. I understand that this information will remain confidential to the designated persons trained in first aid or emergency personnel as needed. Participant Signature Date

6 What to bring to AnyTown Checklist REQUIRED ITEMS Clothes o Keep it simple. You ll be spending a lot of time outdoors and engaging in activities. Dress Comfortably. Ideal clothes include jeans, t-shirts, shorts, sweatshirts, etc. o Please bring a comfortable pair of closed toe shoes. o A poncho, raincoat, or umbrella is a good idea in case of rain. o Bathing suit, there is a pool. o Clothes should be appropriate! Please refrain from short shirts and skirts or midriff bearing halter tops, sagging pants that show your underwear, clothing of a questionable, offensive or suggestive nature. Sheets, pillows, and blankets beds are twin sized. Toiletries o Toothbrush, toothpaste, soap, shampoo, etc. o Sunscreen Towel and washcloth Approved personal medications A good attitude!!! OPTIONAL ITEMS Musical instruments or sheet music Cultural clothing and artifacts Meaningful books, stories, or poetry Camera and film Please put your name on everything so personal items don t get mixed up or lost. Personal/Portable CD players or IPODS for free time only. Telephones, pagers or communication devices. They are only allowed briefly at AnyTown during free time and may not work considering the facility is in the woods. If someone needs to contact you, a telephone is provided ( ). DO NOT BRING Portable radios, tv s, dvd players, game systems, etc. We have a stereo for our group use for which you can bring appropriate CD s to play. IPOD s/personal/portable CD players are OK for free time. Weapons, fireworks, alcohol or illegal substances. None of these are allowed. ANYONE bringing these items will be sent home and appropriate legal actions may be taken. PLEASE NOTE: AnyTown is a community built on trust and therefore you should not have any items stolen. However, we are not responsible for any lost or stolen items.