Tropical Medicine and International HealthCan a comprehensive voucher programme prompt changes indoctors’ knowledge, attitudes and practices related to sexualand reproductive health care for adolescents? A case study fromLatin AmericaLiesbeth E. Meuwissen1,2, Anna C. Gorter2, Arnold D. M. Kester3 and J. A. Knottnerus1,41 Department of General Practice, University of Maastricht, The Netherland
Child of volunteer application packetPLEASE ATTACH
A PHOTO OF
Please complete all sides of this application and return to the Camp Hope® office:
Child of a Volunteer Fee: $100
NAME: ____________________________________________________ NAME USED: _______________________________ ADDRESS: _________________________________________________________________ APT/LOT #: ________________ ION CITY/STATE/ZIP: _____________________________________________COUNTY: _______________ TA GENDER: GIRL BOY DATE OF BIRTH: _______/_______/________ HOME PHONE #: __________________________________ SCHOOL ATTENDING: ___________________________________________________
PARENT’S NAME: ________________________________________________________________________________________
EER APPLICT HOME PHONE: _____________________________________ WORK PHONE: ______________________________________ N CELL PHONE: ____________________________________E-MAIL ADDRESS:_________________________________________ ADDITIONAL INFORMATION
VOLU Church Home_______________________________________________________________________ Church Telephone Number_____________________ Sr. Pastor Name _________________________ Favorite craft activity____________________________ Favorite outside activity _________________________ CHILD OF A Favorite team sport ____________________________ Skill level of swimming (circle one): None Beginner Intermediate Advanced T-Shirt Size (circle one) Child size S M L OR Adult size S M L XL
Camp Hope®, Cornerstone and the Leadership Training Academy are ministries of kidz2leaders®, inc.
4385 Lower Roswell Road, Marietta, GA 30068 www.camphopeforkidz.org/www.kidz2leaders.org Phone 770.977.7751 Fax 770.977.0552 kidz2leaders®, inc. is an IRS approved 501(c)(3) corporation. As such, contributions are tax deductible.
HEALTH HISTORY FORM
Required for all Children, Youth and Adults attending Camp Hope®
The information on this form is gathered to assist us in providing a safe and healthy camp experience for all participants. Health history forms
must be filled out by parents/guardians of minors or by adults themselves and submitted with application. Medical information critical to the
health and well-being of a camper/participant may be shared with their head counselor/director.
Participant’s Name: ______________________________________________________________________ Birth Date: ____________________ Last Home Address: _______________________________________________________________________________________________________ Gender: Female Male Custodial Parent/Guardian (if child is a minor): _______________________________________ Home Phone: ____________________________ Work Phone: ____________________________ Cell Phone: ____________________________ Social Security # of Participant (optional): _______________________ Camp Hope® personnel MUST be able to reach custodial parent during the entire week of camp in the event your child needs to
come home due to illness, injury or disciplinary reasons.
EMERGENCY CONTACT #1 EMERGENCY
Name: ______________________________________________ Name: ______________________________________________ Home Phone: ________________________________________ Home Phone: ________________________________________ Cell Phone: __________________________________________ Cell Phone: __________________________________________ Work Phone: _________________________________________ Work Phone: _________________________________________ INSURANCE INFORMATION
Is the participant covered by family medical/hospital insurance? Yes No Insurance Company:_______________________________________________ Phone Number: ____________________________________ Name of Policy Holder:__________________________________________ Policy Number: _______________________________________ Social Security # of Insured Person: _______________________ CONSENT FOR MEDICAL TREATMENT (MINOR)
I, __________________________________ (Parent/Guardian's Name) hereby give permission to kidz2leaders®, inc., their representatives, agents and
employees for any and all medical attention to be administered to my child, _____________________________________ (Child's Name), in the event of accident,
injury, sickness, or the like. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent until such time
as I may be contacted. I also assume the responsibility for the payment of any such treatment. This release is effective from Saturday, July 12, 2008 until Friday,
July 18, 2008, inclusive. In compliance with HIPPA, I have contacted my Physician’s office to let them know that I give kidz2leaders®, inc. personnel permission
to contact said office in the event kidz2leaders®, inc. personnel needs medical history information on my child.
CONSENT FOR MEDICAL TREATMENT (if adult of legal age)
I hereby give my consent for emergency medical care for myself as prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve my life, limb or well-being. In compliance with HIPPA, I have contacted my Physician’s office to let them
know that I give kidz2leaders®, inc. personnel permission to contact said office in the event kidz2leaders®, inc. personnel needs my medical history information.
RELEASE OF LIABILITY
kidz2leaders®, inc. (k2l) d/b/a Camp Hope®, the Leadership Training Academy (LTA) and Cornerstone will not assume any liability for any accident of
participants in their group while at the Rock Eagle 4-H Center. Utmost caution will be taken at all times to ensure participant’s safety. The undersigned releases the
Rock Eagle Center and kidz2leaders®, inc., their representatives, agents, and employees from liability resulting from the cause whatsoever occurring to a
participant during the stay at the center, excepting only willful acts of such representatives, agents, servants and employees. I also certify that the Health
Information Form is correct and complete to the best of my knowledge, and that the person herein described has permission to engage in all camp activities except
as noted. I am the legal parent or guardian for the minor child that I am sending to Camp Hope®.
Signature of Parent/Guardian or Adult Counselor/Staffer _____________________________________________________________________ Guardian Printed Name ______________________________________________________ Date ___________________________________
Notary: Sworn to and subscribed before me this __________________ day of ________________________________________________, 2008.
Name ______________________________________________________ Notary Public, State of ____________________________________.
My commission expires _________________________________________Seal __________________________________________________ HEALTH INFORMATION NAME:
Health History/Allergies (Please check all that Apply)
Medications_______________________________ Recent Injuries:
Do you carry an inhaler with you? _________ Grasses, hay, etc. __________________________ Do you carry an EpiPen® with you? _________ Other allergies_____________________________ Please list any significant medical or surgical history, any hospitalization or doctor visits for an illness in the past year:
MEDICATIONS THAT MAY BE ADMINISTERED AT CAMP: The Camp Hope® Clinic stocks the following medications in the event that you/your child
should require them. These medications are administered by a health professional under the direction of our Camp Physician. Please do not bring the
following medications to camp with you.
Medication Authorization—please check which one you agree to:
I hereby give permission to Camp Hope® medical personnel to administer any of the above medications per the label instructions by age/weight PRN.
I hereby give permission to Camp Hope® medical personnel to administer any of the above medications per the label instructions by age/weight PRN with
the following exceptions: ______________________________________________________________________________
All prescription medications must be turned into the camp nurse upon arrival and be in it’s original, labeled container, which tells the camper’s
name, dose, frequency and duration to be administered at camp.
List any medications routinely taken (especially those taken during school year): ____________________________________________________ ____________________________________________________________________________________________________________________ Reason for medication (be specific):________________________________________________________________________________________
Other medical information you should know about me/my child: __________________________________________________________________
Does your child experience difficulty managing anger? Yes No Explain: _______________________________________________
Are the camper’s/staffer’s immunizations up to date? Yes No Date of last physical: ____________________________________
ACTIVITIES (Please explain any limitations to activities, reason for restriction and what adaptations or limitations are necessary)
____________________________________________________________________________________________________________________ Name of Physician: __________________________________________________________Phone: ___________________________________
Name of Dentist/Orthodontist: ________________________________________________ Phone: __________________________________
For office use only (Health Check-In Questions)
Screened by _________________________________ For office use only (Health Check-In Questions)
Screened by _________________________________ Date Screened __________ Time ________ am pm Updates/additions to health history noted Yes No None Required Date Screened __________ Time ________ am pm Updates/additions to health history noted Yes No None Required Meds received ______________________________________________________________________________________________________ Meds received ______________________________________________________________________________________________________ List any current health needs ide tified _______ ____________________________________________________________________________ tified ___________________________________________________________________________________ Observational Notes ___________________________________________________________________________________________________ Observational Notes ___________________________________________________________________________________________________ CONFIDENTIAL INFORMATION
Tell us a little bit about your child. Any suggestions/information you give will be helpful to staff members trying to provide your child a fun, worthwhile camping experience. 1. Has your child spent the night away from home before? _______ Please list any concerns: _________________________ ___________________________________________________________________________________________________ 2. Are there any special requests you have concerning your child’s bedtime routine? ___________________________________________________________________________________________________ 3. What is your child looking forward to most in his/her camping experience? _______________________________________ 4. Does your child have any learning, physical, or emotional issues about which we should be aware? If so, please give a brief explanation: ________________________________________________________________________________________ 5. Are there any activities at camp that should be avoided? _____________________________________________________ 6. Is your child allergic to any medications or food? ________ If so, what? ________________________________________ Note From Ms. Diane, Director and Founder of Camp Hope®: You will be able to see your child(ren) several times during the day (meal times, large group activities,
worship, etc.) so please do not visit the kidzkamp cabin to tell your child(ren) “good night” as this may
start and/or increase tears. Also, if Mom or Dad shows up, it sets off a chain reaction. I promise we
will come get you if there is a problem. We need you to be a Mom or Dad for the children in your
Thank you for your understanding, This application packet must be completed on all sides and notarized for it be considered complete
You may pay ON-LINE at www. camphope4kidz.org, or
attach a check payable to “Camp Hope” for your Child of a Volunteer fees of $100.
Please return EVERYTHING to the Camp Hope® office no later than May 27, 2008.
FEMA Cross-reference List This is a cross-reference list of addresses to the August 29, 2008 FEMA list of structures that are not located in the Special Flood Hazard Area. The flood plain gods have smiled on you! The page numbering starts with the first page of addresses - not the FEMA cover letter. The FEMA list has several typo's and omissions. So when there is a cross-reference to a