z - 2023 Express C.A.M.P Parent/Guardian Paperwork and Payment Form

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• Legal Name of Student*
  First Name Last Name
• Preferred Name for Child's Name Badge
  First Name Last Name
• Child's Date of Birth (xx/xx/xxx)*
• Legal Guardian Address*
  Street Address Street Address Line 2 City State / Province / Region ZIP / Postal Code
• Child's Gender*
• Grade Fall 2023*
  • 1st
  • 2nd
  • 3rd
  • 4th
  • 5th
• Name of Child's School*
• Name of Parent or Guardian*
  First Name Last Name
• Parent/Guardian Email Address*
• Parent/Guardian Phone Number (Area Code + Number)*
• Non Parent/Guardian Emergency Contact*
  First Name Last Name
• Non Parent/Guardian Emergency Contact Phone Number (Area Code + Number)*

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• Medical Section

  Please be aware that Express C.A.M.P. has both indoor and outdoor activities. We provide campers with bug spray, sunscreen and water. Please send a water bottle with your child to camp each day.
• Acknowledgment of COVID Policy*
  I agree to the COVID policy outlined below.
  The Program recommends that all campers and staff be vaccinated for COVID 19. All campers and staff may or may not be required to wear masks (regardless of vaccination status) during camp based on DePauw University's COVID protocols and policies.
• Medical Insurance Company*
• Policy Holder's Name*
• Policy/Group#/Phone*
• Medication Allergies
  Please list any medications your child is allergic to, and describe the reaction and appropriate management of reaction.
• Food Allergies
  Please list any foods your child is allergic to, and describe the reaction and appropriate management of reaction.
• Other Allergies
  Please list any other things (pet dander, insect bites, etc.) your child is allergic to, and describe the reaction and appropriate management of reaction.
• Dietary Restrictions
  Please list any dietary restrictions your child may have.

• Medications

  List all medications the child will take DURING the Program/Visit (including things like "epi" pens). This includes any prescription, non-prescription medications, herbal supplements, and vitamins. Parent/guardian should give all medications to the adult program leader in their original containers with complete dispensing instructions before the start of the Program. The Minor program participant must be able to self-medicate. If the Minor cannot self-medicate, the parent/guardian must make arrangements with a third-party health care professional in advance of the arrival of the Minor at the Program. Minors will be allowed to carry personal “epi” pens and inhalers for self-administration.

• Medication Name/Dose/Treatment for/Dispensing Instructions (including amount of medication and time to dispense)
• Accessibility Information
  Please list anything you would like us to know about your child's accessibility needs. Does your child have any disabilities or chronic conditions that would require any restrictions or accommodations to activity? What accommodations or limitations are necessary?
• Has your child had any recent injury, illness, or infectious disease?*
  • Yes
  • No
• Has your child been diagnosed with asthma?*
  • Yes
  • No
• Is your child currently under a doctor’s care for seizures?*
  • Yes
  • No
• Has your child been diagnosed with diabetes?*
  • Yes
  • No
• Does your child have any chronic stomach/intestinal issues?*
  • Yes
  • No
• Does your child experience frequent/heavy nose bleeds?*
  • Yes
  • No
• Does your child experience frequent headaches or migraines?*
  • Yes
  • No
• Does your child experience fainting or dizziness?*
  • Yes
  • No
• Please explain any “yes” answers here.
• Has your child ever been treated for attention deficit disorder (ADD) or attention deficit/hyperactivity disorder (ADHD)?*
  • Yes
  • No
• Has your child seen a professional to address mental/emotional health concerns in the last 12 months?*
  • Yes
  • No
• Has your child had a significant life event that continues to affect the child’s life? (Answer only if you feel it will be relevant during camp.)
  • Yes
  • No
• Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the camp should be aware.
• Authorization of Consent to Medical Treatment of Minor in an Emergency*
  I consent to the policy outlined below.
  Should my child require emergency medical treatment, first aid, or transportation to a hospital or medical facility as a result of illness or injury associated with my child’s participation in the Program, I consent to any such treatment, first aid and/or transportation that may be provided to my child, permit Program staff and/or staff of the University Office of Public Safety to provide medically related information from this consent form to treating athletic trainers and/or medical providers, and understand that the Program and DePauw University will not be responsible for any costs associated with any of the foregoing.
  
  This authorization shall remain effective from July 10, 2023, through July 14, 2023, unless sooner terminated in writing.

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• Transportation

  The Prindle Insitute is offering transportation within Greencastle City limits. The drivers will be certified drivers from the university.

• Camp-Provided Transportation

• Will your child require transportation provided by the camp to and from camp each day?*
  • Yes
  • No
• Pick Up / Drop Off Address*
• If you choose to use camp-provided transportation for your child, please initial below to acknowledge and accept responsibility for your child upon the Prindle Institute staff dropping off your child and the address listed above:

• Car

• If your child will be picked up via car each day, please provide a list of people authorized to take your child:

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• Media Release

• I authorize the Program and/or DePauw University to publish or release to the media any pictures or video of my child taken during their time as a participant in the Program for promotional or recognition purposes only.*
  • Yes
  • No

• Field Trip Transportation

• Should the Program in which my Minor child is participating require transport of participants by motor vehicle, I authorize the Program staff to arrange for and provide transportation services.*
  • Yes
  • No

• Swimming

• My child may swim Friday afternoon, July 14. (A Red Cross certified Lifeguard will be on duty and some of the camp staff will be present to supervise.) If you choose "no," your child will participate in another activity with a member of camp staff.*
  • Yes
  • No
• My child's swimming ability is:*
  • Beginner
  • Intermediate
  • Advanced

• General Release of Liability

• I understand that my child will be a participant in a Program affiliated with DePauw University, and I hereby give permission for them to participate.
  I understand that my child will be provided with the orientation and training necessary, and as needed, for the safe and responsible participation in the Program.
  I understand that my child may participate in physical activity. I represent and warrant that my child is in good physical condition and has no physical, health-related or other problems which would preclude or restrict their safe participation in this Program or otherwise render their participation dangerous or harmful to themselves or others and that they are allowed to participate in physical activity.
  I, the undersigned, certify that I am the parent or legal guardian of the child named above and that I have the right to make decisions for my child that affect their well-being. I recognize and acknowledge that physical injury, accident, illness, death, loss of personal property, or other contingencies may befall my child as a participant in the Program. I understand that my child is not in any way required to participate in the preceding. In light of the preceding and with sufficient knowledge of my child’s physical and other conditions and limitations, if any, I voluntarily assume all responsibility and risk of loss, damage, illness, and/or injury to person or property which my child may, in any way, sustain in connection with their participation in the Program. I agree to release the Program and its medical providers, DePauw University, its trustees, officers, employees, agents and volunteers from any and all liabilities, damages, losses and/or causes of action (collectively “Claims”) that I or my child may suffer or have, including without limitation, to our persons or property or both, which arise out of, are related to or in connection with, or occur during my child’s participation in or attendance in the Program except to the extent such Claims are caused by the gross negligence or willful misconduct of the staff or the Program and/or agents of DePauw University. I further agree to indemnify and hold harmless the Program and its staff, and DePauw University and its trustees, officers, employees, and volunteers from any and all Claims arising out of, related to, or in connection with the Program that are caused by my or my child’s negligent or intentionally tortuous acts or omissions.

• I CERTIFY THAT I AM 18 YEARS OF AGE OR OLDER AND THAT I HAVE READ, FULLY UNDERSTAND AND AGREE TO THE TERMS OF THIS AGREEMENT, AND I SIGN IT VOLUNTARILY AND WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

• E-Signature of Parent or Legal Guardian*
• Date of Submission (xx/xx/xxxx)*

• DePauw University utilizes the Campus Conduct Hotline, a program of the Educational & Institutional Insurance Administrators, Inc (EIIA), for confidential and anonymous reporting of questionable and/or unethical behavior. Should you or your child observe or experience activity and/or behavior that you consider harmful, unethical, questionable or which causes you and yours personal injury, you are invited to file a confidential report by calling 866-943-5787.

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• The counselors of Express C.A.M.P (Character, Attitude, Morals, and Perspective) and Prindle Institute camp staff want to offer your child the best experience possible while attending our camp this summer. Therefore, we need each camper to understand and follow the camp guidelines and rules. These guidelines are in place to ensure the safety and well-being of your child, fellow campers and camp staff.
  -Wear a mask when required by Program staff and/or DePauw University -Listen to camp counselors and staff members.
  -Respect camp counselors, staff, and fellow camp participants.
  -Respect camp property, the Prindle Institute, and field trip locations.
  -Keep your hands, feet, and other objects to yourself.
  -Use an indoor voice when indoors.
  -When riding the bus, respect the bus driver and fellow campers, and remain seated at all times.
  -Follow the counselors’ instructions at all times, including field trips to the nature park, the pool, and the campus farm.
  -Clean up after yourself.
  -Be positive, kind to others, and have fun!
  Should a camper choose not to follow the rules, the steps listed below will be used to handle the situation:
  1) Redirection of camper to change behavior
  2) One verbal warning
  3) Time away from the group with a camp counselor or staff member
  4) Conversation/phone call with the parents/guardians and follow up letter will be sent home
  5) Removal from the camp
  If the camper engages in behavior that is a threat of bodily harm to themselves or others, or the physical property, parents or guardians will be called immediately. If such behavior warrants, a meeting with parents may be needed and could result in suspension or removal from camp.
  Situations that will result in an automatic behavior warning report include: stealing, use of profanity, excessive violence (hitting, kicking, biting, etc) and property damage.
  Please review these rules and expectations with your child. The camp staff will also review these rules with your child at the beginning of camp.
  By signing this form, I acknowledge that I have reviewed the behavior policy with my child and understand that if my child is removed from Express C.A.M.P I am not entitled to a tuition refund.
• E-Signature of Parent/Guardian Acknowledging Behavior Policy*

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• Payment

• Have you discussed receiving a scholarship with Emily Knuth?*
  • Yes
  • No
• Select payment amount (no scholarship)*
  First child/only child (Express C.A.M.P. registration)Additional child/sibling (Express C.A.M.P. registration)
• Select payment amount*
  Level 1 ($150)Level 2 ($100)Level 5 ($25)Level 6 ($0)
• Total (No scholarship)
  $0.00
• Total
  $0.00
• Credit Card
  Card Details

  Cardholder Name
• Credit Card
  Card Details

  Cardholder Name

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